Provider Demographics
NPI:1154597201
Name:LANGSTON, MATTHEW DWIGHT (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DWIGHT
Last Name:LANGSTON
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 1:1400 PELHAM PARKWAY SOUTH
Mailing Address - Street 2:JACOBI MEDICAL CENTER
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-918-5696
Mailing Address - Fax:718-918-4510
Practice Address - Street 1:1400 PELHAM PARKWAY SOUTH
Practice Address - Street 2:JACOBI MEDICAL CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-918-5696
Practice Address - Fax:718-918-4510
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118423207R00000X, 207RC0200X, 207RP1001X
NY269819-1207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118423Medicaid
206147OtherMEDICARE PTAN (GROUP)
206147050OtherMEDICARE PTAN (INDIVIDUAL)
ILP00946731OtherMEDICARE RAILROAD PTAN (GROUP)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)
ILP00946731OtherMEDICARE RAILROAD PTAN (GROUP)
206147OtherMEDICARE PTAN (GROUP)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)