Provider Demographics
NPI:1336112465
Name:LANGSTON, ANDY (OD, PA)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:LANGSTON
Suffix:
Gender:M
Credentials:OD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY ISLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72631-9221
Mailing Address - Country:US
Mailing Address - Phone:479-253-4040
Mailing Address - Fax:479-253-5636
Practice Address - Street 1:1 PARK DR STE B
Practice Address - Street 2:
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631-9221
Practice Address - Country:US
Practice Address - Phone:479-253-4040
Practice Address - Fax:479-253-5636
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126039722Medicaid
U38481Medicare UPIN
AR126039722Medicaid
AR4571990001Medicare NSC