Healthcare Provider Details

I. General information

NPI: 1912910993
Provider Name (Legal Business Name): JENNIFER BETH LONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 S DOUGLAS RD SUITE B
MIRAMAR FL
33025-2734
US

IV. Provider business mailing address

3220 S DOUGLAS RD SUITE B
MIRAMAR FL
33025-2734
US

V. Phone/Fax

Practice location:
  • Phone: 954-436-8444
  • Fax: 954-436-1159
Mailing address:
  • Phone: 954-436-8444
  • Fax: 954-436-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME93226
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: