Provider Demographics
NPI:1043208523
Name:LONG, MOLLY M (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:M
Last Name:LONG
Suffix:
Gender:F
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:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:603 7TH ST S
Practice Address - Street 2:SUITE 300
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4719
Practice Address - Country:US
Practice Address - Phone:727-954-7121
Practice Address - Fax:727-954-7122
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00752014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272448100Medicaid
FL272448100Medicaid
FL03538ZMedicare ID - Type Unspecified