Healthcare Provider Details

I. General information

NPI: 1013603810
Provider Name (Legal Business Name): KATELYN HAGSTROM MARILAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELYN ANNE HAGSTROM MD

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WPAFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-0770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberV9615
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: