Healthcare Provider Details

I. General information

NPI: 1053300939
Provider Name (Legal Business Name): ELISABETH ANN HAGEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4613 40TH ST N
ARLINGTON VA
22207-2961
US

IV. Provider business mailing address

4613 40TH ST N
ARLINGTON VA
22207-2961
US

V. Phone/Fax

Practice location:
  • Phone: 301-518-4676
  • Fax:
Mailing address:
  • Phone: 301-518-4676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD034566
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberD0061008
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: