Provider Demographics
NPI:1689720054
Name:MICHAEL J. BANGERT O.D. INC.
Entity Type:Organization
Organization Name:MICHAEL J. BANGERT O.D. INC.
Other - Org Name:FAMILY EYECARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BANGERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-432-5502
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN56000085A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0679970001Medicare NSC
IN410005869Medicare PIN
INDT7543Medicare PIN
INM100064007Medicare PIN