MEDICARE: DR. JEFFREY MICHAEL LONG OD

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	152W00000X	Optometrist	2341	OK
2	152WC0802X	Corneal and Contact Management Optometrist	2341	OK
3	152WP0200X	Pediatric Optometrist	2341	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770602302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY MICHAEL LONG OD

Provider Business Mailing Address
First Line	:	7374 S. OLYMPIA AVE.
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74132-1849
Country	:	US
Telephone Number	:	918-794-2020
Fax Number	:	918-794-2720

Provider Business Practice Location Address
First Line	:	7374 S. OLYMPIA AVE.
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74132-1849
Country	:	US
Telephone Number	:	918-794-2020
Fax Number	:	918-794-2720

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	10/12/2012

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