Healthcare Provider Details

I. General information

NPI: 1609843457
Provider Name (Legal Business Name): MARVIN LANGFORD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date: 05/07/2018
Reactivation Date: 02/19/2019

III. Provider practice location address

175 SAMARITAN DR
JASPER GA
30143-1964
US

IV. Provider business mailing address

PO BOX 2547
BLUE RIDGE GA
30513-0044
US

V. Phone/Fax

Practice location:
  • Phone: 706-253-4673
  • Fax:
Mailing address:
  • Phone: 706-258-2091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5494
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: