Healthcare Provider Details

I. General information

NPI: 1063679652
Provider Name (Legal Business Name): DANIEL LANGSAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 491 N NORTHERN NAVAJO MEDICAL CENTER
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6001
  • Fax:
Mailing address:
  • Phone: 505-368-6001
  • Fax: 505-368-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2017-0476
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: