Provider Demographics
NPI:1528122173
Name:DAGENAIS, VERNE (OD)
Entity type:Individual
Prefix:
First Name:VERNE
Middle Name:
Last Name:DAGENAIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:182 W 32ND ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8127
Practice Address - Country:US
Practice Address - Phone:928-726-7757
Practice Address - Fax:928-726-2239
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ481197Medicaid
AZ481197Medicaid
AZZ163453Medicare PIN
AZ134875Medicare PIN
AZZ163454Medicare PIN
AZZ163457Medicare PIN
AZZ163458Medicare PIN
AZZ163455Medicare PIN
AZZ162078Medicare PIN
AZZ162074Medicare PIN
AZZ1620175Medicare PIN
AZZ163455Medicare PIN
AZZ163454Medicare PIN