Provider Demographics
NPI:1467644724
Name:LANGE, JOHN I
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:LANGE
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 FARMINGTON AVE
Mailing Address - Street 2:121
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1505
Mailing Address - Country:US
Mailing Address - Phone:860-232-8800
Mailing Address - Fax:
Practice Address - Street 1:836 FARMINGTON AVE
Practice Address - Street 2:121
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1505
Practice Address - Country:US
Practice Address - Phone:860-232-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTLO764156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1236400001Medicare PIN