Provider Demographics
NPI:1902890833
Name:LANGE, JOHN PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:LANGE
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 1:1171 N COTNER BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-1835
Mailing Address - Country:US
Mailing Address - Phone:402-466-6070
Mailing Address - Fax:402-466-6178
Practice Address - Street 1:1171 N COTNER BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-1835
Practice Address - Country:US
Practice Address - Phone:402-466-6070
Practice Address - Fax:402-466-6178
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47064095500Medicaid
NE087658Medicare UPIN
NE095956Medicare ID - Type UnspecifiedMEDICARE