Healthcare Provider Details

I. General information

NPI: 1013112283
Provider Name (Legal Business Name): LONG HA HUYNH M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LONG HA HUYNH MD., PH.D.

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax: 618-529-0449
Mailing address:
  • Phone: 618-549-0752
  • Fax: 618-529-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD600854844
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036149496
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: