MEDICARE: EVAN ANDREW LONGFIELD

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	207Y00000X	Otolaryngology Physician	R3553	TX

General Provider Information

NPI Number	:	1417215344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN ANDREW LONGFIELD

Provider Business Mailing Address
First Line	:	1908 N LAURENT ST STE 410
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-5469
Country	:	US
Telephone Number	:	361-572-0333
Fax Number	:	361-371-7090

Provider Business Practice Location Address
First Line	:	800 W CENTRAL TEXAS EXPY STE 205
Second Line	:
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1996
Country	:	US
Telephone Number	:	254-618-1095
Fax Number	:	254-618-1101

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

Provider Enumeration Date	:	04/28/2012
Last Update Date	:	09/27/2019

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