Provider Demographics
NPI:1811152044
Name:HAGEN, JUSTIN T (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N KEENE STREET
Mailing Address - Street 2:SUITE 404
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201
Mailing Address - Country:US
Mailing Address - Phone:573-777-7627
Mailing Address - Fax:573-777-4596
Practice Address - Street 1:404 N KEENE STREET
Practice Address - Street 2:SUITE 404
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-777-7627
Practice Address - Fax:573-777-4596
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080117891208000000X
MO2011012289208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics