Healthcare Provider Details

I. General information

NPI: 1053350751
Provider Name (Legal Business Name): LARRY LYNN HAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 20TH ST
HUNTINGTON WV
25703-2019
US

IV. Provider business mailing address

1001 20TH ST
HUNTINGTON WV
25703-2019
US

V. Phone/Fax

Practice location:
  • Phone: 304-529-6100
  • Fax: 304-529-0229
Mailing address:
  • Phone: 304-529-6100
  • Fax: 304-529-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number22558
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: