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General NPI Number Information
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NPI Number | 1558663781
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Entity Type | Individual
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Provider Name | THOMAS EUGENE LONG M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/19/2010
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Last Update Date | 11/19/2010
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Provider Practice Location Address
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Address Line | 1841 NUGGET DR
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86404-1813
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Country | US
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Telephone | 928-453-8880
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Fax | 928-453-8880
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Provider Business Mailing Address
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Address Line | PO BOX 5505
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86404-0201
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Country | US
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Telephone | 928-453-8880
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Fax | 928-453-8880
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34402
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License Number State | AZ
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