Provider Demographics
NPI:1912092743
Name:LANGHAM, CHARLES G III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:LANGHAM
Suffix:III
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 1:1307 8TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-921-6091
Mailing Address - Fax:817-921-9163
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-921-6091
Practice Address - Fax:817-921-9163
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4467174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123419702Medicaid
TX123419702Medicaid