Provider Demographics
NPI:1043207988
Name:LONGOBARDO, VINCENT B (DPM)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:B
Last Name:LONGOBARDO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557-0008
Mailing Address - Country:US
Mailing Address - Phone:931-707-8352
Mailing Address - Fax:931-707-8053
Practice Address - Street 1:19 MIRACLE LN
Practice Address - Street 2:SUITE 200
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-7654
Practice Address - Country:US
Practice Address - Phone:931-707-8352
Practice Address - Fax:931-707-8053
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000520213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3352893Medicaid
TN3352893Medicare PIN
TN1308330001Medicare NSC
TN3352893Medicaid