Provider Demographics
NPI:1316905169
Name:HAGEDORN, GREGORY BRENT (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BRENT
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-0577
Mailing Address - Country:US
Mailing Address - Phone:270-826-1500
Mailing Address - Fax:270-827-0757
Practice Address - Street 1:1413 N ELM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2768
Practice Address - Country:US
Practice Address - Phone:270-826-1500
Practice Address - Fax:270-827-0757
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1016DT152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010163Medicaid
KY9249401Medicare PIN
KY77010163Medicaid
KY0425620001Medicare NSC