Provider Demographics
NPI:1891759767
Name:LANGENBERG, MARK TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TAYLOR
Last Name:LANGENBERG
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 1:500 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-1718
Mailing Address - Country:US
Mailing Address - Phone:931-823-5681
Mailing Address - Fax:931-823-7235
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-1718
Practice Address - Country:US
Practice Address - Phone:931-823-5681
Practice Address - Fax:931-823-8203
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35093207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3875548Medicaid
TN3875548Medicaid
TNH65407Medicare UPIN