Healthcare Provider Details

I. General information

NPI: 1538124110
Provider Name (Legal Business Name): JOHN LAWRENCE HEGSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N NEVADA AVENUE
COLORADO SPRINGS CO
80907
US

IV. Provider business mailing address

PO BOX 744127
DALLAS TX
75374-0968
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-5000
  • Fax:
Mailing address:
  • Phone: 719-776-5816
  • Fax: 719-776-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number23966
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG7526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: