Provider Demographics
NPI:1073719910
Name:DR JERRY W LONG OPTOMETRY
Entity Type:Organization
Organization Name:DR JERRY W LONG OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMOTRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-785-8476
Mailing Address - Street 1:213 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5135
Mailing Address - Country:US
Mailing Address - Phone:573-785-8476
Mailing Address - Fax:573-785-8477
Practice Address - Street 1:213 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5135
Practice Address - Country:US
Practice Address - Phone:573-785-8476
Practice Address - Fax:573-785-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500398706Medicaid
MO310038807Medicaid
MO000006948Medicare ID - Type UnspecifiedDR. LONG'S PROVIDER #
MO500398706Medicaid
MO310038807Medicaid
MO990001270Medicare ID - Type UnspecifiedGROUP NUMBER