Healthcare Provider Details

I. General information

NPI: 1346407962
Provider Name (Legal Business Name): ADRIAN LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6573 A1A S
SAINT AUGUSTINE FL
32080-7504
US

IV. Provider business mailing address

6573 A1A S
SAINT AUGUSTINE FL
32080-7504
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-7363
  • Fax: 904-342-7367
Mailing address:
  • Phone: 904-342-7363
  • Fax: 904-342-7367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME109167
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: