Healthcare Provider Details

I. General information

NPI: 1760405534
Provider Name (Legal Business Name): MITCHELL D LONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 12TH AVE RD
NAMPA ID
83686-6008
US

IV. Provider business mailing address

2463 EASTDALE DR
BOISE ID
83712-6724
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-5100
  • Fax:
Mailing address:
  • Phone: 208-343-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0-273
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: