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General NPI Number Information
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NPI Number | 1689834400
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Entity Type | Organization
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Legal Business Name | WARREN DAVID. LONG
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Dates
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Enumeration Date | 06/16/2008
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 2625 LINE AVE 155
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City | SHREVEPORT
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State | LA
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Zip | 71104-3047
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Country | US
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Telephone | 318-424-8436
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Fax | 318-424-8438
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Provider Business Mailing Address
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Address Line | 2625 LINE AVE 155
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City | SHREVEPORT
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State | LA
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Zip | 71104-3047
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Country | US
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Telephone | 318-424-8436
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Fax | 318-424-8438
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Authorized Official
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Title or Position | MD/OWNER
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Name | DR. WARREN DAVID LONG JR.
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Credential | MD
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Telephone | 318-424-8436
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 02812R
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License Number State | LA
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