Provider Demographics
NPI:1033164736
Name:LONG, CHARLES DAVID (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1250 GREENWOOD AVE
Mailing Address - Street 2:STE 14
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2902
Mailing Address - Country:US
Mailing Address - Phone:215-572-6888
Mailing Address - Fax:215-572-5905
Practice Address - Street 1:1250 GREENWOOD AVE
Practice Address - Street 2:STE 14
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2902
Practice Address - Country:US
Practice Address - Phone:215-572-6888
Practice Address - Fax:215-572-5905
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2011-05-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD043562L208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA043791 - GROUPOtherMEDICARE
PA867646OtherPERSONAL CHOICE
PA052949OtherPERSONAL CHOICE GRP
PA052949OtherBLUE SHIELD
PA0018274790004Medicaid
PA0016511000OtherKEYSTONE HEALTH PLAN EAST