Provider Demographics
NPI:1194503862
Name:LONG, ROBERT HENRY SR
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:HENRY
Last Name:LONG
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 STANTON AVE APT C36
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-2343
Mailing Address - Country:US
Mailing Address - Phone:515-360-1377
Mailing Address - Fax:
Practice Address - Street 1:2200 STANTON AVE APT C36
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-2343
Practice Address - Country:US
Practice Address - Phone:515-360-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA824YY1420172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver