Healthcare Provider Details

I. General information

NPI: 1205098738
Provider Name (Legal Business Name): DANXUAN LONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

IV. Provider business mailing address

PO BOX 19656
SPRINGFIELD IL
62794-9656
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-1350
  • Fax: 217-464-1359
Mailing address:
  • Phone: 217-545-8853
  • Fax: 217-545-0828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036128323
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036128323
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036128323
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: