Provider Demographics
NPI:1992906747
Name:HAGEDORN, DAVID WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 VALENCIA DRIVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7807
Mailing Address - Country:US
Mailing Address - Phone:910-353-1760
Mailing Address - Fax:910-353-1763
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL - FAMILY MEDICINE
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547
Practice Address - Country:US
Practice Address - Phone:910-450-8805
Practice Address - Fax:910-353-1763
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1117103TC0700X
WAPY00003898103TC0700X
TX32594103TC2200X
NC3745103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent