Healthcare Provider Details

I. General information

NPI: 1285641449
Provider Name (Legal Business Name): ROGER KENJI LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 PARNASSUS AVE # S672
SAN FRANCISCO CA
94143-0434
US

IV. Provider business mailing address

513 PARNASSUS AVE # S672
SAN FRANCISCO CA
94143-0434
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-0750
  • Fax: 415-476-8214
Mailing address:
  • Phone: 415-476-0750
  • Fax: 415-476-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA74233
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA74233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: