Healthcare Provider Details

I. General information

NPI: 1578529855
Provider Name (Legal Business Name): JERRY LEE BANGERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7356 NORTH LA CHOLLA BLVD.
TUCSON AZ
85741
US

IV. Provider business mailing address

PO BOX 844777
DALLAS TX
75284-4777
US

V. Phone/Fax

Practice location:
  • Phone: 520-575-1007
  • Fax: 214-596-7422
Mailing address:
  • Phone: 888-344-1160
  • Fax: 972-331-3148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11270
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number11270
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: