Provider Demographics
NPI:1275612749
Name:LONGO, NICOLA (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8732
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLAZA SUITE 3100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1287
Practice Address - Country:US
Practice Address - Phone:310-301-8732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12808207SG0202X
UT4916705-1205207SG0202X
CAC196187207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics