Healthcare Provider Details

I. General information

NPI: 1356458806
Provider Name (Legal Business Name): LANCE P LONGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LANCE PETER LONGO

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 DEWEY AVE
WAUWATOSA WI
53213-2598
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-773-4311
  • Fax: 414-454-6747
Mailing address:
  • Phone: 800-326-2250
  • Fax: 414-671-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number74570
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number37822
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: