Provider Demographics
NPI:1144259086
Name:BOMGAARS, DAVID NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:NICHOLAS
Last Name:BOMGAARS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTN: LYNDA THOMPSON
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:6245 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4001
Practice Address - Country:US
Practice Address - Phone:734-458-3412
Practice Address - Fax:734-677-7407
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010708752085R0202X, 174H00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174H00000XOther Service ProvidersHealth Educator
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3108298622OtherBCBS INDIVIDUAL PIN #
MI300H220260OtherGROUP #
MI4514997Medicaid
MI0N55390020Medicare PIN
MI4514997Medicaid