Provider Demographics
NPI:1194923862
Name:LONG, HEATHER BETH (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:BETH
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 NW 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2564
Mailing Address - Country:US
Mailing Address - Phone:913-219-0183
Mailing Address - Fax:
Practice Address - Street 1:15970 SE MISTY DR STE 100
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-4368
Practice Address - Country:US
Practice Address - Phone:503-427-2637
Practice Address - Fax:503-659-8984
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007017298390200000X
ORMD151090208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500624770Medicaid