Provider Demographics
NPI:1013216373
Name:BANGART, KEITH THOMAS (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:THOMAS
Last Name:BANGART
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13660 N 94TH DR
Mailing Address - Street 2:#F1
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4836
Mailing Address - Country:US
Mailing Address - Phone:623-974-0522
Mailing Address - Fax:623-933-5787
Practice Address - Street 1:13660 N 94TH DR
Practice Address - Street 2:#F1
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4836
Practice Address - Country:US
Practice Address - Phone:623-974-0522
Practice Address - Fax:623-933-5787
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0724213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0724OtherLICENSE #
AZ6647440001OtherNSC PTAN
FB2444812OtherDEA #