Provider Demographics
NPI:1023045762
Name:LONG, ROBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1600 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-1411
Mailing Address - Country:US
Mailing Address - Phone:719-546-4495
Mailing Address - Fax:719-546-4476
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:719-546-4495
Practice Address - Fax:719-546-4476
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO383012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E48337Medicare UPIN