Provider Demographics
NPI:1164484705
Name:BANGMA, LEON JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:JAMES
Last Name:BANGMA
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 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:
Practice Address - Street 1:2897 RADCLIFF AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-1793
Practice Address - Country:US
Practice Address - Phone:616-942-2710
Practice Address - Fax:616-942-8680
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5175734Medicaid
MI4450521Medicaid
MI5175734Medicaid
MIP21400002Medicare PIN
MIM29060-003Medicare ID - Type Unspecified
MI5472600013Medicare PIN
MI4450521Medicaid
MIP32620004Medicare PIN
MI0P32620Medicare PIN