Healthcare Provider Details

I. General information

NPI: 1316905169
Provider Name (Legal Business Name): GREGORY BRENT HAGEDORN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 N ELM ST SUITE 102
HENDERSON KY
42420-2768
US

IV. Provider business mailing address

PO BOX 577
HENDERSON KY
42419-0577
US

V. Phone/Fax

Practice location:
  • Phone: 270-826-1500
  • Fax: 270-827-0757
Mailing address:
  • Phone: 270-826-1500
  • Fax: 270-827-0757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1016DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1016DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: