Provider Demographics
NPI:1053345835
Name:LANG, JACOB R (OD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:LANG
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 1:1719 TOWER DR W STE 100
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7512
Mailing Address - Country:US
Mailing Address - Phone:651-439-3050
Mailing Address - Fax:
Practice Address - Street 1:2950 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5085
Practice Address - Country:US
Practice Address - Phone:651-275-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN163427500Medicaid
MNP00324834OtherRAILROAD MEDICARE
MNP00324834OtherRAILROAD MEDICARE
MN163427500Medicaid