Basic Information
| Provider Information | |||||||||
| NPI: | 1669474896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEGSTROM | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 308 | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814020308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704978416 | ||||||||
| FaxNumber: | 9704678410 | ||||||||
| Practice Location | |||||||||
| Address1: | 2351 G RD | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815059641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706443237 | ||||||||
| FaxNumber: | 9706443259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | DR.0025745 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 74609858 | 05 | CO | MEDICAID |