Healthcare Provider Details

I. General information

NPI: 1841266608
Provider Name (Legal Business Name): CHARLES A LONGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S. CLIFF AVE STE 3000
SIOUX FALLS SD
57105-1061
US

IV. Provider business mailing address

2400 S MINNESOTA AVE STE 100
SIOUX FALLS SD
57105-3762
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-7600
  • Fax: 605-322-7601
Mailing address:
  • Phone: 605-322-7510
  • Fax: 605-322-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number5192
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: