Provider Demographics
NPI:1962579037
Name:LONG, GEOFFREY STEWART (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:STEWART
Last Name:LONG
Suffix:
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 1:1890 METRO CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5286
Mailing Address - Country:US
Mailing Address - Phone:703-709-1500
Mailing Address - Fax:703-709-1697
Practice Address - Street 1:1890 METRO CENTER DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5222
Practice Address - Country:US
Practice Address - Phone:703-709-1500
Practice Address - Fax:703-709-1697
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HO7643Medicare UPIN
490463Medicare ID - Type Unspecified