Provider Demographics
NPI:1285691501
Name:LONG, MARK ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3745 CHEROKEE ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144
Mailing Address - Country:US
Mailing Address - Phone:770-429-1005
Mailing Address - Fax:770-429-8005
Practice Address - Street 1:3745 CHEROKEE ST
Practice Address - Street 2:SUITE 401
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-429-1005
Practice Address - Fax:770-429-8005
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA048265208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G83209Medicare UPIN