Healthcare Provider Details

I. General information

NPI: 1669799664
Provider Name (Legal Business Name): MINDY MARIE HAGSTROM O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MINDY MARIE ANDERSON O.D.

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 E SOUTHERN AVE STE 1508
MESA AZ
85206-3724
US

IV. Provider business mailing address

3635 E INVERNESS AVE STE 105
MESA AZ
85206-3848
US

V. Phone/Fax

Practice location:
  • Phone: 809-643-5424
  • Fax: 480-240-9120
Mailing address:
  • Phone: 480-345-7520
  • Fax: 480-844-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1720
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: