Healthcare Provider Details

I. General information

NPI: 1700013638
Provider Name (Legal Business Name): BRYAN EDWARD LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL RESEARCH AND TRAINING COMMAND SAN DIEGO 34800 BOB WILSON DRIVE
SAN DIEGO CA
92009
US

IV. Provider business mailing address

NAVAL MEDICAL RESEARCH AND TRAINING COMMAND SAN DIEGO 34800 BOB WILSON DRIVE
SAN DIEGO CA
92009
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-5432
  • Fax: 619-532-8055
Mailing address:
  • Phone: 619-532-5432
  • Fax: 619-532-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC-151803
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number151803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: