Healthcare Provider Details

I. General information

NPI: 1508913989
Provider Name (Legal Business Name): DOMINIQUE NOE LONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE S NOE

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST PARK 211
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64316
BALTIMORE MD
21264-4316
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberD59951
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: