Provider Demographics
NPI:1053300939
Name:HAGEN, ELISABETH ANN (MD)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:ANN
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4613 40TH ST N
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-2961
Mailing Address - Country:US
Mailing Address - Phone:301-518-4676
Mailing Address - Fax:
Practice Address - Street 1:4613 40TH ST N
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-2961
Practice Address - Country:US
Practice Address - Phone:301-518-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD034566207RI0200X
MDD0061008207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G96181Medicare UPIN
DC012559D02Medicare ID - Type Unspecified