Provider Demographics
NPI:1962575563
Name:HAGSTROM, MATS (MD)
Entity type:Individual
Prefix:
First Name:MATS
Middle Name:
Last Name:HAGSTROM
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 1:909 HYDE ST STE 423
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4846
Mailing Address - Country:US
Mailing Address - Phone:415-885-4343
Mailing Address - Fax:
Practice Address - Street 1:909 HYDE ST STE 210
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4845
Practice Address - Country:US
Practice Address - Phone:415-475-9809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG807212086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG72483Medicare UPIN