Provider Demographics
NPI:1760487607
Name:MASSIGNAN, DALE T (OD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:T
Last Name:MASSIGNAN
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:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-0999
Mailing Address - Country:US
Mailing Address - Phone:715-479-6489
Mailing Address - Fax:715-479-6200
Practice Address - Street 1:523 EAST WALL STREET
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521
Practice Address - Country:US
Practice Address - Phone:715-479-6489
Practice Address - Fax:715-479-6200
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38517000Medicaid
WI000087388Medicare ID - Type Unspecified
WI0135820001Medicare NSC
WI38517000Medicaid