Healthcare Provider Details

I. General information

NPI: 1376172932
Provider Name (Legal Business Name): MATTHEW LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 MCKEAN ST BLDG 291
SAN DIEGO CA
92136-5000
US

IV. Provider business mailing address

2730 MCKEAN ST BLDG 291
SAN DIEGO CA
92136-5220
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-8464
  • Fax:
Mailing address:
  • Phone: 802-338-5164
  • Fax: 619-532-8353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA204278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: