Provider Demographics
NPI:1235188871
Name:STAGG, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:STAGG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 FARMINGTON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1915
Mailing Address - Country:US
Mailing Address - Phone:860-674-0111
Mailing Address - Fax:
Practice Address - Street 1:231 FARMINGTON AVE STE 201
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1915
Practice Address - Country:US
Practice Address - Phone:860-674-0111
Practice Address - Fax:860-677-5406
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U79827Medicare UPIN