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General NPI Number Information
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NPI Number | 1477800134
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Entity Type | Individual
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Provider Name | MATTHEW HAGAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/12/2012
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Last Update Date | 06/23/2021
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Provider Practice Location Address
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Address Line | 1855 MADISON AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83404-1212
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Country | US
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Telephone | 208-881-5351
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3446
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City | IDAHO FALLS
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State | ID
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Zip | 83403-3446
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Country | US
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Telephone | 208-552-8580
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Fax | 208-523-2025
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036145857
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MT201381
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | M-15773
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | M-15773
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License Number State | ID
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