Provider Demographics
NPI:1639128887
Name:DAGAN, JODY LYN (OD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:LYN
Last Name:DAGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21821 N 40TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7235
Mailing Address - Country:US
Mailing Address - Phone:480-220-8970
Mailing Address - Fax:480-292-9836
Practice Address - Street 1:3303 S LINDSAY RD
Practice Address - Street 2:STE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-6503
Practice Address - Country:US
Practice Address - Phone:480-292-9835
Practice Address - Fax:480-292-9836
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1214152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
102221Medicare ID - Type Unspecified
V04545Medicare UPIN