Healthcare Provider Details

I. General information

NPI: 1851036867
Provider Name (Legal Business Name): CODY W DAGNALL OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W FULTON ST # 1422
WAUPACA WI
54981-1422
US

IV. Provider business mailing address

424 S MAIN ST
FALL RIVER WI
53932-9594
US

V. Phone/Fax

Practice location:
  • Phone: 715-258-8168
  • Fax:
Mailing address:
  • Phone: 920-296-2031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3809
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: