Provider Demographics
NPI:1316948516
Name:DAGENAIS, MARK A (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:DAGENAIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3670 S 108TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53228-1237
Mailing Address - Country:US
Mailing Address - Phone:414-453-1010
Mailing Address - Fax:262-542-9439
Practice Address - Street 1:3670 S 108TH ST STE 204
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53228-1237
Practice Address - Country:US
Practice Address - Phone:414-453-1010
Practice Address - Fax:414-425-4230
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38603400Medicaid
WI5291780001Medicare NSC
WI000347145Medicare ID - Type Unspecified
WI38603400Medicaid