Provider Demographics
NPI:1699065839
Name:KEITH BANGART DPM PC
Entity type:Organization
Organization Name:KEITH BANGART DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGART
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-974-0522
Mailing Address - Street 1:13660 N 94TH DR STE F1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4232
Mailing Address - Country:US
Mailing Address - Phone:623-974-0522
Mailing Address - Fax:623-933-5787
Practice Address - Street 1:13660 N 94TH DR STE F1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4232
Practice Address - Country:US
Practice Address - Phone:623-974-0522
Practice Address - Fax:623-933-5787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0724213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0724OtherAZ LICENSE
AZ0724OtherAZ LICENSE