Healthcare Provider Details

I. General information

NPI: 1265745871
Provider Name (Legal Business Name): YASHA S LONG MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N 10TH ST EMERGENCY DEPARTMENT
SANTA PAULA CA
93060-1309
US

IV. Provider business mailing address

133 W SANTA CLARA ST
VENTURA CA
93001-2543
US

V. Phone/Fax

Practice location:
  • Phone: 805-933-8600
  • Fax:
Mailing address:
  • Phone: 805-641-5731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number6406
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA126009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: