Provider Demographics
NPI:1235455437
Name:BANGERT, ORSON DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:ORSON
Middle Name:DANIEL
Last Name:BANGERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6611
Mailing Address - Fax:608-756-6236
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6611
Practice Address - Fax:608-756-6236
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI61194-21207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI123545537OtherBCBSWI
WIBANGEORSOtherMERCYCARE INSURANCE
WI123545537Medicaid
WI123545537OtherBCBSWI
WI123545537Medicaid