Provider Demographics
NPI:1396707220
Name:LANG, PAUL T (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:LANG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1005 CHARLEVOIX DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8186
Mailing Address - Country:US
Mailing Address - Phone:517-337-1668
Mailing Address - Fax:517-622-1205
Practice Address - Street 1:136 EAST GRAND RIVER AVE.
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48813-1510
Practice Address - Country:US
Practice Address - Phone:517-223-9988
Practice Address - Fax:517-223-9071
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900C848370OtherBCBSM
200000023735OtherPHP
MI0C84837018Medicare PIN
MI0N95630003Medicare ID - Type Unspecified
MI0N83480008Medicare PIN
MI900C848370OtherBCBSM
200000023735OtherPHP