Provider Demographics
NPI:1184054363
Name:DRS. PAUL M GODICH AND MARK A DAGENAIS OPTOMETRISTS LLC
Entity type:Organization
Organization Name:DRS. PAUL M GODICH AND MARK A DAGENAIS OPTOMETRISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAGENAIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:414-425-4141
Mailing Address - Street 1:10555 W PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2000
Mailing Address - Country:US
Mailing Address - Phone:414-425-4141
Mailing Address - Fax:414-425-4230
Practice Address - Street 1:10555 W PARNELL AVE
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2000
Practice Address - Country:US
Practice Address - Phone:414-425-4141
Practice Address - Fax:414-425-4230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-25
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K100114996Medicare PIN
WI687620002Medicare UPIN