Healthcare Provider Details

I. General information

NPI: 1912903071
Provider Name (Legal Business Name): RICHARD J LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 NORRIS CANYON RD STE 210
SAN RAMON CA
94583-5405
US

IV. Provider business mailing address

1450 TREAT BLVD # 300
WALNUT CREEK CA
94597-2168
US

V. Phone/Fax

Practice location:
  • Phone: 925-933-9868
  • Fax:
Mailing address:
  • Phone: 925-952-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number014674
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG89306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: