Healthcare Provider Details

I. General information

NPI: 1851619936
Provider Name (Legal Business Name): JASON D HAGEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E 5TH ST STE 1
DELPHOS OH
45833-9180
US

IV. Provider business mailing address

PO BOX 636930
CINCINNATI OH
45263-6930
US

V. Phone/Fax

Practice location:
  • Phone: 419-692-5611
  • Fax: 419-695-9401
Mailing address:
  • Phone: 513-981-5123
  • Fax: 513-981-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.098971
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.098971
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: