Healthcare Provider Details

I. General information

NPI: 1609834621
Provider Name (Legal Business Name): ERIK LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 MARTIN ST
TWIN FALLS ID
83301-4544
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-0451
  • Fax: 208-734-0452
Mailing address:
  • Phone: 208-734-3312
  • Fax: 208-734-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-9131
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: