Provider Demographics
NPI:1003127465
Name:VANDEN LANGENBERG, RACHAEL E (DO)
Entity Type:Individual
Prefix:DR
First Name:RACHAEL
Middle Name:E
Last Name:VANDEN LANGENBERG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:RACHAEL
Other - Middle Name:E
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3263 EATON RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6830
Mailing Address - Country:US
Mailing Address - Phone:920-433-6700
Mailing Address - Fax:
Practice Address - Street 1:3263 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6830
Practice Address - Country:US
Practice Address - Phone:920-433-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013624207Q00000X
PAOS015861207Q00000X
WI61517-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61517-21OtherSTATE LICENSE
WIK400121195Medicare Oscar/Certification
WIK400115123Medicare Oscar/Certification