Provider Demographics
NPI:1396370466
Name:LANGSTON, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:LANGSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:LANGSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3618 DAWNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7971
Mailing Address - Country:US
Mailing Address - Phone:317-767-9912
Mailing Address - Fax:
Practice Address - Street 1:3618 DAWNWOOD DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7971
Practice Address - Country:US
Practice Address - Phone:317-767-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8972311612171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty