Provider Demographics
NPI:1114212255
Name:LANGE, DAVID OTTO (BS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:OTTO
Last Name:LANGE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 NOTT ST
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-4346
Mailing Address - Country:US
Mailing Address - Phone:518-374-3324
Mailing Address - Fax:
Practice Address - Street 1:2205 NOTT ST
Practice Address - Street 2:
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-4346
Practice Address - Country:US
Practice Address - Phone:518-374-3324
Practice Address - Fax:518-374-3325
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00536094Medicaid