Healthcare Provider Details

I. General information

NPI: 1508791369
Provider Name (Legal Business Name): GAGE MICHAEL KOON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13197 STATE ROAD 23
GRANGER IN
46530-9225
US

IV. Provider business mailing address

13197 STATE ROAD 23
GRANGER IN
46530-9225
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-1500
  • Fax: 574-247-1505
Mailing address:
  • Phone: 574-247-1500
  • Fax: 574-247-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004649A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: