Healthcare Provider Details

I. General information

NPI: 1477036887
Provider Name (Legal Business Name): CASEY BUNGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 W GANSON ST
JACKSON MI
49202-4240
US

IV. Provider business mailing address

220 LYNDENGLEN DR APT 103
ANN ARBOR MI
48103-6981
US

V. Phone/Fax

Practice location:
  • Phone: 877-852-8463
  • Fax:
Mailing address:
  • Phone: 815-509-3553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301518204
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: