Provider Demographics
NPI:1295705846
Name:LANG, AMANDA L (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:L
Last Name:LANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 LAWNDALE ST
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2921
Mailing Address - Country:US
Mailing Address - Phone:231-845-6261
Mailing Address - Fax:231-843-9171
Practice Address - Street 1:5959 LAWNDALE ST
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2921
Practice Address - Country:US
Practice Address - Phone:231-845-6261
Practice Address - Fax:231-843-9171
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI004110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4921634Medicaid
900F410030OtherBCBS OF MICHIGAN
MI4620819Medicaid
MI4620828Medicaid
P00138760OtherRAILROAD MEDICARE
900F410030OtherBCBS OF MICHIGAN
MI4620828Medicaid