Provider Demographics
NPI:1124645585
Name:BANNON, MICHAEL JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:BANNON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 POPLAR PATH
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1828
Mailing Address - Country:US
Mailing Address - Phone:262-490-7697
Mailing Address - Fax:
Practice Address - Street 1:1500 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6404
Practice Address - Country:US
Practice Address - Phone:920-261-9225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3625-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist