Provider Demographics
NPI:1851036867
Name:DAGNALL, CODY W (OD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:W
Last Name:DAGNALL
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 1:424 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:53932-9594
Mailing Address - Country:US
Mailing Address - Phone:920-296-2031
Mailing Address - Fax:
Practice Address - Street 1:308 W FULTON ST # 1422
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1422
Practice Address - Country:US
Practice Address - Phone:715-258-8168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist