Provider Demographics
NPI:1801464409
Name:M LANGFORD OD OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:M LANGFORD OD OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-760-8348
Mailing Address - Street 1:4310 GENESEE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4936
Mailing Address - Country:US
Mailing Address - Phone:858-560-5181
Mailing Address - Fax:858-560-1926
Practice Address - Street 1:4310 GENESEE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-4936
Practice Address - Country:US
Practice Address - Phone:858-560-5181
Practice Address - Fax:858-560-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14061OtherOD LICENSE