Provider Demographics
NPI:1578655502
Name:LANGSTON, GERRY D (DC, DABCI)
Entity Type:Individual
Prefix:
First Name:GERRY
Middle Name:D
Last Name:LANGSTON
Suffix:
Gender:M
Credentials:DC, DABCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4503 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2905
Mailing Address - Country:US
Mailing Address - Phone:918-747-5555
Mailing Address - Fax:918-747-1028
Practice Address - Street 1:4503 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2905
Practice Address - Country:US
Practice Address - Phone:918-747-5555
Practice Address - Fax:918-747-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2112111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQDCGWMedicare UPIN
OKT79969Medicare ID - Type UnspecifiedID#