Healthcare Provider Details

I. General information

NPI: 1962575563
Provider Name (Legal Business Name): MATS HAGSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 HYDE ST STE 210
SAN FRANCISCO CA
94109-4845
US

IV. Provider business mailing address

909 HYDE ST STE 423
SAN FRANCISCO CA
94109-4846
US

V. Phone/Fax

Practice location:
  • Phone: 415-475-9809
  • Fax:
Mailing address:
  • Phone: 415-885-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberG80721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: