Provider Demographics
NPI:1720069982
Name:STAGNER, MICHAEL JAMES (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:STAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4800 N 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4963
Mailing Address - Country:US
Mailing Address - Phone:602-955-1000
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:40 CAPRI BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5661
Practice Address - Country:US
Practice Address - Phone:928-855-9477
Practice Address - Fax:928-855-2983
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ24627207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ359788Medicaid
AZ359788003Medicaid
AZ1312670001Medicare NSC
AZF58206Medicare UPIN