Basic Information
| Provider Information | |||||||||
| NPI: | 1740247014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAGAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD | ||||||||
| Address2: | BLDG 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043991717 | ||||||||
| Practice Location | |||||||||
| Address1: | 3627 UNIVERSITY BLVD S | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043995678 | ||||||||
| FaxNumber: | 9043998488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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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 | 208600000X | ME61915 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00062700 | 01 | FL | RAILROAD MEDICARE | OTHER | 102532 | 01 | FL | AVMED | OTHER | 1717114 | 01 | FL | CIGNA | OTHER | 4565405 | 01 | FL | AETNA | OTHER | 18738 | 01 | FL | BCBS | OTHER |