Provider Demographics
NPI:1558663781
Name:LONG, THOMAS EUGENE (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:EUGENE
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 5505
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-0201
Mailing Address - Country:US
Mailing Address - Phone:928-453-8880
Mailing Address - Fax:928-453-8880
Practice Address - Street 1:1841 NUGGET DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-1813
Practice Address - Country:US
Practice Address - Phone:928-453-8880
Practice Address - Fax:928-453-8880
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ34402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD62344Medicare UPIN