Provider Demographics
NPI:1043876295
Name:LONG, ZACHARY (OD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
Last Name:LONG
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 1:3211 PEOPLES ST STE 55
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4109
Mailing Address - Country:US
Mailing Address - Phone:423-328-5189
Mailing Address - Fax:423-952-4953
Practice Address - Street 1:3211 PEOPLES ST STE 55
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4109
Practice Address - Country:US
Practice Address - Phone:423-328-5189
Practice Address - Fax:423-952-4953
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist