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General NPI Number Information
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NPI Number | 1801003496
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Entity Type | Organization
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Legal Business Name | LONG DERMATOLOGY PA
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Dates
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Enumeration Date | 05/16/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 155 N NOVA RD
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City | ORMOND BEACH
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State | FL
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Zip | 32174-5138
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Country | US
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Telephone | 386-672-3111
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Fax | 386-672-6532
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Provider Business Mailing Address
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Address Line | 155 N NOVA RD
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City | ORMOND BEACH
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State | FL
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Zip | 32174-5138
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Country | US
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Telephone | 386-672-3111
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Fax | 386-672-6532
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Authorized Official
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Title or Position | OWNER
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Name | JOHN C LONG JR.
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Credential | MD
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Telephone | 386-672-3111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | ME68137
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License Number State | FL
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