Provider Demographics
NPI:1295838316
Name:BANWART, MICHAEL ERIC (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:BANWART
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 1:2401 MONIQUE LN APT 2
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-2439
Mailing Address - Country:US
Mailing Address - Phone:406-868-7836
Mailing Address - Fax:
Practice Address - Street 1:2001 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-8337
Practice Address - Country:US
Practice Address - Phone:715-486-9365
Practice Address - Fax:715-486-1426
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3005-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist