Provider Demographics
NPI:1467450478
Name:LANGE, JORY D (MD)
Entity Type:Individual
Prefix:
First Name:JORY
Middle Name:D
Last Name:LANGE
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 1:3711 MARY MONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-3415
Mailing Address - Country:US
Mailing Address - Phone:210-616-0866
Mailing Address - Fax:
Practice Address - Street 1:8038 WURZBACH RD
Practice Address - Street 2:SUITE 270
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3817
Practice Address - Country:US
Practice Address - Phone:210-616-0866
Practice Address - Fax:210-616-0868
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX300018335OtherRR MEDICARE
TX120215205Medicaid
TX120215205Medicaid
TXE08957Medicare UPIN