Provider Demographics
NPI:1104811835
Name:LONGO, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:LONGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 N 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-2037
Mailing Address - Country:US
Mailing Address - Phone:402-556-4617
Mailing Address - Fax:
Practice Address - Street 1:311 S CLARK ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3038
Practice Address - Country:US
Practice Address - Phone:712-792-8265
Practice Address - Fax:712-792-8264
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA301352085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0177261Medicaid
IAF94115Medicare UPIN
IA0177261Medicaid