Healthcare Provider Details

I. General information

NPI: 1518044072
Provider Name (Legal Business Name): EDWARD LANGSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W. CAMP STREET
LEBANON IN
46052-1647
US

IV. Provider business mailing address

4818 W HARRISBURG CT
NEW PALESTINE IN
46163-8546
US

V. Phone/Fax

Practice location:
  • Phone: 765-482-7005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01026184
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: