MEDICARE: DR. JOHN CHARLES LONG JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME0068137	FL

General Provider Information

NPI Number	:	1356351043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN CHARLES LONG JR. MD

Provider Business Mailing Address
First Line	:	155 N NOVA RD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5138
Country	:	US
Telephone Number	:	386-672-3111
Fax Number	:	386-672-6532

Provider Business Practice Location Address
First Line	:	155 N NOVA RD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5138
Country	:	US
Telephone Number	:	386-672-3111
Fax Number	:	386-672-6532

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. JOHN CHARLES LONG JR. MD” Practice Location

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