Healthcare Provider Details

I. General information

NPI: 1144259086
Provider Name (Legal Business Name): DAVID NICHOLAS BOMGAARS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 INKSTER RD
GARDEN CITY MI
48135-4001
US

IV. Provider business mailing address

PO BOX 1108 ATTN: LYNDA THOMPSON
ANN ARBOR MI
48106-1108
US

V. Phone/Fax

Practice location:
  • Phone: 734-458-3412
  • Fax: 734-677-7407
Mailing address:
  • Phone: 734-677-7400
  • Fax: 734-677-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301070875
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number4301070875
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301070875
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: