Healthcare Provider Details

I. General information

NPI: 1417933516
Provider Name (Legal Business Name): STEVEN E LONGACRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 REESE LN
AZLE TX
76020-1539
US

IV. Provider business mailing address

6451 BRENTWOOD STAIR RD STE 200
FORT WORTH TX
76112-3200
US

V. Phone/Fax

Practice location:
  • Phone: 214-632-1863
  • Fax:
Mailing address:
  • Phone: 817-507-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberK8305
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: