Provider Demographics
NPI:1033523329
Name:LONG, DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 W AMERICAN DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1993
Mailing Address - Country:US
Mailing Address - Phone:920-725-9373
Mailing Address - Fax:920-720-7392
Practice Address - Street 1:1305 W AMERICAN DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1993
Practice Address - Country:US
Practice Address - Phone:800-201-1194
Practice Address - Fax:920-725-7392
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010209412084N0400X
WI70781-212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100088599Medicaid