Healthcare Provider Details

I. General information

NPI: 1669474896
Provider Name (Legal Business Name): TODD E. HEGSTROM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 G RD
GRAND JUNCTION CO
81505-9641
US

IV. Provider business mailing address

PO BOX 308
MONTROSE CO
81402-0308
US

V. Phone/Fax

Practice location:
  • Phone: 970-644-3237
  • Fax: 970-644-3259
Mailing address:
  • Phone: 970-497-8416
  • Fax: 970-467-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0025745
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: