Provider Demographics
NPI:1992778906
Name:LONG, WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
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 1:8401 MEDICAL PLAZA DR
Mailing Address - Street 2:STE 365
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8700
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-316-1800
Practice Address - Fax:704-316-1773
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25614207RG0300X, 207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN25614Medicaid
NC8952803Medicaid
NCC81467Medicare UPIN
NC202760JMedicare ID - Type Unspecified