Provider Demographics
NPI:1497782031
Name:LANGSTON, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LANGSTON
Suffix:
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 1:1717 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1801
Practice Address - Country:US
Practice Address - Phone:800-822-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL219082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051529345OtherBLUE CROSS
AL009984960Medicaid
AL051529343OtherBLUE CROSS
AL051529344OtherBLUE CROSS
AL009984950Medicaid
AL010033CH56469OtherSECTION 1011
AL009936827Medicaid
AL051529347OtherBLUE CROSS
AL009932492Medicaid
AL009909495Medicaid
MS09781031OtherMISSISSIPPI MEDICAID
ALH56469OtherVIVA
AL051551643Medicare PIN