MEDICARE: DR. MINDY MARIE HAGSTROM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT-001720	AZ

General Provider Information

NPI Number	:	1669799664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINDY MARIE HAGSTROM O.D.

Provider Business Mailing Address
First Line	:	8614 WESTWOOD CENTER DR FL 9
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-2442
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	3635 E INVERNESS AVE STE 107
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-3848
Country	:	US
Telephone Number	:	480-372-8950
Fax Number	:	480-835-1222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2010
Last Update Date	:	03/23/2026

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