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: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38400 BOB WILSON DR
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

200 MERCY CIR
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 802-338-5164
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: