Provider Demographics
NPI:1073175329
Name:LONG, AUBREY L (OD)
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9031 VALLEY CREST LN
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7829
Mailing Address - Country:US
Mailing Address - Phone:901-757-2020
Mailing Address - Fax:901-234-0133
Practice Address - Street 1:9031 VALLEY CREST LN
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7829
Practice Address - Country:US
Practice Address - Phone:901-757-2020
Practice Address - Fax:901-234-0133
Is Sole Proprietor?:No
Enumeration Date:2019-07-07
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3529OtherTN LICENSE