Healthcare Provider Details

I. General information

NPI: 1861983959
Provider Name (Legal Business Name): CAMERON TYLER LONGFELLOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD STOP 7200
DALLAS TX
75390-7200
US

IV. Provider business mailing address

1931 MARKET CENTER BLVD APT 5414
DALLAS TX
75207-3496
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-7708
  • Fax:
Mailing address:
  • Phone: 903-253-5538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: