Provider Demographics
NPI:1851392781
Name:AGREN, STUART H
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:H
Last Name:AGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3048 E BASELINE RD
Mailing Address - Street 2:STE 122
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-7286
Mailing Address - Country:US
Mailing Address - Phone:480-827-9945
Mailing Address - Fax:480-834-6244
Practice Address - Street 1:3048 E BASELINE RD
Practice Address - Street 2:STE 122
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7286
Practice Address - Country:US
Practice Address - Phone:480-827-9945
Practice Address - Fax:480-834-6244
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15251174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWDBGJMedicare ID - Type Unspecified
AZC99034Medicare UPIN