Provider Demographics
NPI:1649343930
Name:STAVENGER, DOUGLAS JOHN (ABO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOHN
Last Name:STAVENGER
Suffix:
Gender:M
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 SO UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-235-5185
Mailing Address - Fax:701-232-4965
Practice Address - Street 1:1547 SO UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-235-5185
Practice Address - Fax:701-232-4965
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND5822980001Medicare NSC