Provider Demographics
NPI:1619096799
Name:BANGERT, MARIBETH ANDERSON (OD)
Entity type:Individual
Prefix:DR
First Name:MARIBETH
Middle Name:ANDERSON
Last Name:BANGERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 CREEKWOOD CT SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9780
Mailing Address - Country:US
Mailing Address - Phone:616-664-0973
Mailing Address - Fax:
Practice Address - Street 1:3819 RIVERTOWN PKWY SW
Practice Address - Street 2:SUITE 500
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3140
Practice Address - Country:US
Practice Address - Phone:616-667-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004140152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU-93003Medicare UPIN
MION59310Medicare ID - Type Unspecified