Provider Demographics
NPI:1396720355
Name:LANG, MAYNARD F (MD)
Entity type:Individual
Prefix:DR
First Name:MAYNARD
Middle Name:F
Last Name:LANG
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 1:3400 DATA DRIVE
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES, 2ND FLOOR
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:782 EAST HARDING WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-6101
Practice Address - Country:US
Practice Address - Phone:209-475-5500
Practice Address - Fax:209-466-1982
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29340208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C293401Medicare ID - Type Unspecified
CAA33887Medicare UPIN