Provider Demographics
NPI:1386711455
Name:JOHN B LONG MD A PROFESSIONAL CORP
Entity type:Organization
Organization Name:JOHN B LONG MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-750-3887
Mailing Address - Street 1:3838 CALIFORNIA ST RM 612
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1508
Mailing Address - Country:US
Mailing Address - Phone:415-750-3887
Mailing Address - Fax:415-221-7052
Practice Address - Street 1:3838 CALIFORNIA ST RM 612
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1508
Practice Address - Country:US
Practice Address - Phone:415-750-3887
Practice Address - Fax:415-221-7052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG409742086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22937ZMedicare PIN