Healthcare Provider Details

I. General information

NPI: 1023087343
Provider Name (Legal Business Name): DEANNE LONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 ARAPEEN DR STE 110
SALT LAKE CITY UT
84108-1250
US

IV. Provider business mailing address

540 ARAPEEN DR STE #110
SALT LAKE CITY UT
84108-1250
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-4268
  • Fax: 801-582-4269
Mailing address:
  • Phone: 801-582-4268
  • Fax: 801-582-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4752590-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4752590-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number4752590-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: