Healthcare Provider Details

I. General information

NPI: 1578655502
Provider Name (Legal Business Name): GERRY D. LANGSTON D.C., D.A.B.C.I.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4503 S HARVARD AVE
TULSA OK
74135-2905
US

IV. Provider business mailing address

4503 S HARVARD AVE
TULSA OK
74135-2905
US

V. Phone/Fax

Practice location:
  • Phone: 918-747-5555
  • Fax: 918-747-1028
Mailing address:
  • Phone: 918-747-5555
  • Fax: 918-747-1028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number2112
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: