Provider Demographics
NPI:1386962439
Name:DAVID A LONG MD, PA
Entity type:Organization
Organization Name:DAVID A LONG MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-381-7727
Mailing Address - Street 1:1615 PASADENA AVE S
Mailing Address - Street 2:250
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4516
Mailing Address - Country:US
Mailing Address - Phone:727-381-7727
Mailing Address - Fax:727-381-8229
Practice Address - Street 1:1615 PASADENA AVE S
Practice Address - Street 2:250
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4516
Practice Address - Country:US
Practice Address - Phone:727-381-7727
Practice Address - Fax:727-381-8229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044825700Medicaid
FL62592BMedicare PIN
FL62592QMedicare PIN
FL044825700Medicaid
FLEV484AMedicare PIN