Provider Demographics
NPI:1144277468
Name:HAGAN, DENNIS KEITH (COBBLER)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:KEITH
Last Name:HAGAN
Suffix:
Gender:M
Credentials:COBBLER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 E JOHN ROWAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2066
Mailing Address - Country:US
Mailing Address - Phone:502-349-7119
Mailing Address - Fax:
Practice Address - Street 1:1240 E JOHN ROWAN BLVD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2066
Practice Address - Country:US
Practice Address - Phone:502-349-7119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90011388Medicaid
KY000000362306OtherBCBS
KY50009643OtherPASSPORT