Provider Demographics
NPI:1386619393
Name:LONG, JOHN D (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:LONG
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:
Practice Address - Street 1:457 MCLAWS CIR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5645
Practice Address - Country:US
Practice Address - Phone:757-221-0750
Practice Address - Fax:757-229-5168
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234912207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5519515OtherAETNA
LA1980901Medicaid
NC2050373Medicare PIN
NC185807OtherMEDCOST
NC807305OtherPARTNERS
VA1386619393Medicaid
NC141NAOtherBC/BS
SCQ0006EMedicaid
NC5902843Medicaid
NCP00302423Medicare PIN
F46636Medicare UPIN
WV3810010340Medicaid
P00302421Medicare PIN