Provider Demographics
NPI:1386105930
Name:LONG, CLAYTON VANCE (MD)
Entity type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:VANCE
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:918 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2306
Mailing Address - Country:US
Mailing Address - Phone:336-465-5573
Mailing Address - Fax:
Practice Address - Street 1:600 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-6000
Practice Address - Country:US
Practice Address - Phone:980-993-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202201635207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty