Provider Demographics
NPI:1578529855
Name:BANGERT, JERRY LEE (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:BANGERT
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:PO BOX 844777
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4777
Mailing Address - Country:US
Mailing Address - Phone:888-344-1160
Mailing Address - Fax:972-331-3148
Practice Address - Street 1:7356 NORTH LA CHOLLA BLVD.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741
Practice Address - Country:US
Practice Address - Phone:520-575-1007
Practice Address - Fax:214-596-7422
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11270207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ263062Medicaid
AZ263062Medicaid