Healthcare Provider Details

I. General information

NPI: 1568525608
Provider Name (Legal Business Name): TODD G STAGNER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 N HELMER RD
SPRINGFIELD MI
49037-7931
US

IV. Provider business mailing address

228 N HELMER RD
SPRINGFIELD MI
49037-7931
US

V. Phone/Fax

Practice location:
  • Phone: 269-963-5640
  • Fax: 269-963-1666
Mailing address:
  • Phone: 269-963-5640
  • Fax: 269-963-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003590
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: