Provider Demographics
NPI:1861562530
Name:BALGEMANN, MICHAEL GARRETT (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GARRETT
Last Name:BALGEMANN
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:2515 N PROSPECT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1226
Mailing Address - Country:US
Mailing Address - Phone:217-378-2934
Mailing Address - Fax:217-378-2936
Practice Address - Street 1:2515 N PROSPECT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1226
Practice Address - Country:US
Practice Address - Phone:217-378-2934
Practice Address - Fax:217-378-2936
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2010-05-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL046009189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist