1104032275 NPI number — TIMOTHY C. LANG, DDS, MD, PA

Table of content: (NPI 1104032275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104032275 NPI number — TIMOTHY C. LANG, DDS, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMOTHY C. LANG, DDS, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104032275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2030 S PATRICK DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
INDIAN HARBOUR BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32937-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-777-2166
Provider Business Mailing Address Fax Number:
321-777-2191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2030 S PATRICK DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
INDIAN HARBOUR BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32937-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-777-2166
Provider Business Practice Location Address Fax Number:
321-777-2191
Provider Enumeration Date:
05/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LANG
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
CORRIGAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
321-777-2166

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  ME0068501 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 791334 . This is a "UNITED CONCORDIA ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 253999300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 995474 . This is a "COMPBENEFITS FACILITY NUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 27225 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".