Healthcare Provider Details

I. General information

NPI: 1396720355
Provider Name (Legal Business Name): MAYNARD F. LANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 EAST HARDING WAY
STOCKTON CA
95205-6101
US

IV. Provider business mailing address

3400 DATA DRIVE PHYSICIAN SUPPORT SERVICES, 2ND FLOOR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 209-475-5500
  • Fax: 209-466-1982
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC29340
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: