Provider Demographics
NPI:1083604722
Name:LANGLEY, BRADLEY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLEN
Last Name:LANGLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 SNELLING AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2228
Mailing Address - Country:US
Mailing Address - Phone:651-690-1311
Mailing Address - Fax:651-690-2447
Practice Address - Street 1:721 SNELLING AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2228
Practice Address - Country:US
Practice Address - Phone:651-690-1311
Practice Address - Fax:651-690-2447
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN26499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN256867500Medicaid
MNB58391Medicare UPIN
MN80000303Medicare ID - Type Unspecified