Provider Demographics
NPI:1760456792
Name:LANGLEY, CLARK WYNN (MD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:WYNN
Last Name:LANGLEY
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1718 S HENDERSON BLVD
Practice Address - Street 2:#8
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3566
Practice Address - Country:US
Practice Address - Phone:903-983-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145221103Medicaid
TXTIN PLUS 093OtherTRICARE
TX145221101Medicaid
TX080174505Medicare PIN
TXTIN PLUS 093OtherTRICARE
TX145221103Medicaid
TX8K5036Medicare Oscar/Certification
H44300Medicare UPIN