Basic Information
| Provider Information | |||||||||
| NPI: | 1164484705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANGMA | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | SPRING LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494562024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168460620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2897 RADCLIFF AVE SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495121793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422710 | ||||||||
| FaxNumber: | 6169428680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002511 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5175734 | 05 | MI | MEDICAID | 4450521 | 05 | MI | MEDICAID |