Provider Demographics
NPI:1528144946
Name:STAGMAN, KEVIN ALBERT (OD DR OF OPTOMETRY)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALBERT
Last Name:STAGMAN
Suffix:
Gender:M
Credentials:OD DR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N 5179 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53964
Mailing Address - Country:US
Mailing Address - Phone:608-296-1959
Mailing Address - Fax:
Practice Address - Street 1:222 WEST MCCOY BLVD
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660
Practice Address - Country:US
Practice Address - Phone:608-372-1813
Practice Address - Fax:608-372-1824
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T63404Medicare UPIN