Provider Demographics
NPI:1316272495
Name:LANGEMO, NATHAN (OD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LANGEMO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1607
Mailing Address - Country:US
Mailing Address - Phone:952-475-3787
Mailing Address - Fax:888-959-0116
Practice Address - Street 1:7415 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1607
Practice Address - Country:US
Practice Address - Phone:952-475-3787
Practice Address - Fax:888-959-0116
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3304152WS0006X, 152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy