MEDICARE: DR. GREGORY BRENT HAGEDORN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1016DT	KY
2	152WC0802X	Corneal and Contact Management Optometrist	1016DT	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316905169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY BRENT HAGEDORN OD

Provider Business Mailing Address
First Line	:	PO BOX 577
Second Line	:
City	:	HENDERSON
State	:	KY
Zip	:	42419-0577
Country	:	US
Telephone Number	:	270-826-1500
Fax Number	:	270-827-0757

Provider Business Practice Location Address
First Line	:	1413 N ELM ST
Second Line	:	SUITE 102
City	:	HENDERSON
State	:	KY
Zip	:	42420-2768
Country	:	US
Telephone Number	:	270-826-1500
Fax Number	:	270-827-0757

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	07/22/2014

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