Provider Demographics
NPI:1811250467
Name:LONGENBACH, JAMES ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ANDREW
Last Name:LONGENBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:ANDREW
Other - Last Name:LONGENBACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2400 5TH AVE
Mailing Address - Street 2:APT. 338
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1674
Mailing Address - Country:US
Mailing Address - Phone:570-916-5012
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE BLDG H
Practice Address - Street 2:ATTN: MEDICAL STAFF SERVICES
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:904-542-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT214277207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program