Active NPI
Clark Wynn Langley, MD
- Family Medicine Physician
- Kilgore, TX
National Provider Identifier
1760456792
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- L1919
- Practice address
- 1718 S Henderson Blvd
#8
Kilgore, TX 75662-3566 - Phone
- (903) 983-2110
- NPI assigned
- Feb 15, 2006
- Last updated
- Oct 13, 2014
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | L1919 | TX | Primary |
Addresses
Primary practice location
1718 S Henderson Blvd
#8
Kilgore, TX 75662-3566
Mailing address
PO Box 846098
Dallas, TX 75284-6098
Phone (903) 324-6450
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| TIN PLUS 093 | Other | TX | TRICARE |
| 145221103 | Medicaid | TX | |
| 145221101 | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Apr 1, 2020 through Apr 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| East Texas Treatment Center | Past | Accepting new patients |
Interoperability endpoints
- clangley6632@christushealth.direct-ci.net
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Kilgore, TX
- NPI 1023002425
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1139961600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1413158400000",
"number": "1760456792",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 846098",
"city": "DALLAS",
"state": "TX",
"postal_code": "752846098",
"telephone_number": "903-324-6450"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1718 S HENDERSON BLVD",
"address_2": "#8",
"city": "KILGORE",
"state": "TX",
"postal_code": "756623566",
"telephone_number": "903-983-2110"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LANGLEY",
"first_name": "CLARK",
"middle_name": "WYNN",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-15",
"last_updated": "2014-10-13",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "TX",
"license": "L1919",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE",
"identifier": "TIN PLUS 093",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "145221103",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "145221101",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kilgore, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.