Provider Demographics
NPI:1629124151
Name:BANGERT, MICHAEL JAMES (MICHAEL BANGERT, OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:BANGERT
Suffix:
Gender:M
Credentials:MICHAEL BANGERT, OD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:JAMES
Other - Last Name:BANGERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MICHAEL BANGERT OD
Mailing Address - Street 1:4626 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6826
Mailing Address - Country:US
Mailing Address - Phone:260-432-5502
Mailing Address - Fax:260-432-8415
Practice Address - Street 1:4626 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6826
Practice Address - Country:US
Practice Address - Phone:260-432-5502
Practice Address - Fax:260-432-8415
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001776B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN410005869OtherRETIRED RAILROAD MEDICARE
INM40006415Medicare PIN
IN410005869OtherRETIRED RAILROAD MEDICARE
INP00671548Medicare PIN
INT69230Medicare UPIN
IN0679970001Medicare NSC