Healthcare Provider Details

I. General information

NPI: 1881761948
Provider Name (Legal Business Name): JOHN B LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DANIEL BURNHAM CT
SAN FRANCISCO CA
94109-5455
US

IV. Provider business mailing address

1 DANIEL BURNHAM CT
SAN FRANCISCO CA
94109
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-7056
  • Fax: 415-221-7058
Mailing address:
  • Phone: 415-221-7056
  • Fax: 415-221-7058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG40974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: