Provider Demographics
NPI:1154763340
Name:DO, LONG (OD)
Entity type:Individual
Prefix:DR
First Name:LONG
Middle Name:
Last Name:DO
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 RHONE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1449
Mailing Address - Country:US
Mailing Address - Phone:817-262-2145
Mailing Address - Fax:
Practice Address - Street 1:5201 BOSQUE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4676
Practice Address - Country:US
Practice Address - Phone:254-741-1022
Practice Address - Fax:817-473-0950
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8143TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328585YXC3Medicare PIN