Provider Demographics
NPI:1124168836
Name:LONG, REBECCA A (OD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:LONG-GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3303 CLAIRBORNE XING
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-2969
Mailing Address - Country:US
Mailing Address - Phone:219-246-7807
Mailing Address - Fax:
Practice Address - Street 1:6097 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5215
Practice Address - Country:US
Practice Address - Phone:219-763-1538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002310A152W00000X
IN18002310B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201034350Medicaid
IN11887606OtherCAQH