Provider Demographics
NPI:1235281270
Name:DAHLGREN, BARRY ALBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:ALBERT
Last Name:DAHLGREN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8535 W TRIPOLI AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53228-1723
Mailing Address - Country:US
Mailing Address - Phone:414-543-7383
Mailing Address - Fax:
Practice Address - Street 1:3670 S 108TH ST
Practice Address - Street 2:STE 204
Practice Address - City:GREENFIELD
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?:Yes
Enumeration Date:2007-01-18
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1460152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38511700Medicaid
WI38511700Medicaid
WIT61720Medicare UPIN