Provider Demographics
NPI:1659360345
Name:BANGLMAIER, ROBERT W (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:BANGLMAIER
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:PO BOX 7487
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04112-7487
Mailing Address - Country:US
Mailing Address - Phone:207-885-8686
Mailing Address - Fax:207-883-7154
Practice Address - Street 1:770 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3323
Practice Address - Country:US
Practice Address - Phone:207-772-8384
Practice Address - Fax:207-773-0020
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME295870099Medicaid
MM8374Medicare ID - Type Unspecified
ME295870099Medicaid