Healthcare Provider Details

I. General information

NPI: 1821088873
Provider Name (Legal Business Name): ROBERT E LANGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W EUGIE AVE #100
GLENDALE AZ
85304-1256
US

IV. Provider business mailing address

5601 W EUGIE AVE #100
GLENDALE AZ
85304-1256
US

V. Phone/Fax

Practice location:
  • Phone: 602-978-1500
  • Fax: 602-978-0409
Mailing address:
  • Phone: 602-978-1500
  • Fax: 602-978-0409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number7045
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: