Provider Demographics
NPI:1831206234
Name:HAGEN, JEDD A (MD)
Entity type:Individual
Prefix:
First Name:JEDD
Middle Name:A
Last Name:HAGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3038
Mailing Address - Country:US
Mailing Address - Phone:712-794-5257
Mailing Address - Fax:712-794-5234
Practice Address - Street 1:311 S CLARK ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3038
Practice Address - Country:US
Practice Address - Phone:712-792-8257
Practice Address - Fax:712-792-8234
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30259207ZM0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical Microbiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0119636Medicaid
IA50190OtherBCBS
IA220014555Medicare ID - Type UnspecifiedRAILROAD
IA50190Medicare PIN
IA0119636Medicaid