Provider Demographics
NPI:1154382802
Name:LANGE, JOHN LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LESLIE
Last Name:LANGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 402319
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:5500 ELLSWORTH RD.
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3222
Practice Address - Country:US
Practice Address - Phone:479-242-2411
Practice Address - Fax:479-242-2412
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARN6768208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105907001Medicaid
OK100134360AMedicaid
AR53049OtherBLUE CROSS
OK100134360AMedicaid