Provider Demographics
NPI:1396735346
Name:LONG, LAWRENCE E III (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:E
Last Name:LONG
Suffix:III
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 1:1700 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3317
Mailing Address - Country:US
Mailing Address - Phone:541-296-1111
Mailing Address - Fax:541-269-7601
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-1111
Practice Address - Fax:541-296-7601
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4217A207R00000X
ORMD27040207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR247507Medicaid
WA1067792Medicaid
ORE01449Medicare UPIN
WY307665Medicare ID - Type Unspecified
WA1067792Medicaid