Provider Demographics
NPI:1043366057
Name:LONGENBAUGH, RONALD E (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:E
Last Name:LONGENBAUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N LINE STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-1330
Mailing Address - Country:US
Mailing Address - Phone:260-244-6361
Mailing Address - Fax:260-244-3067
Practice Address - Street 1:512 N LINE STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1330
Practice Address - Country:US
Practice Address - Phone:260-244-6361
Practice Address - Fax:260-244-3067
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002242A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT69305Medicare UPIN
IN930960Medicare ID - Type Unspecified