MEDICARE: DR. MARK A DAGENAIS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2704	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316948516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK A DAGENAIS OD

Provider Business Mailing Address
First Line	:	3670 S 108TH ST STE 204
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53228-1237
Country	:	US
Telephone Number	:	414-453-1010
Fax Number	:	262-542-9439

Provider Business Practice Location Address
First Line	:	3670 S 108TH ST STE 204
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53228-1237
Country	:	US
Telephone Number	:	414-453-1010
Fax Number	:	414-425-4230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	08/16/2024

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