Provider Demographics
NPI:1477553428
Name:GANGLOFF, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GANGLOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SWEET BAY CIR
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2816
Mailing Address - Country:US
Mailing Address - Phone:561-626-3091
Mailing Address - Fax:561-626-3091
Practice Address - Street 1:120 SWEET BAY CIR
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2816
Practice Address - Country:US
Practice Address - Phone:561-626-3091
Practice Address - Fax:561-626-3091
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME825092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
03119ZMedicare ID - Type Unspecified
B39641Medicare UPIN