Provider Demographics
NPI:1083623672
Name:LONG, KATHRYN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1827 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-3017
Mailing Address - Country:US
Mailing Address - Phone:704-910-2250
Mailing Address - Fax:704-817-8539
Practice Address - Street 1:1338 HUNDRED OAKS DR
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-4051
Practice Address - Country:US
Practice Address - Phone:704-910-2250
Practice Address - Fax:704-817-8539
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100065207Q00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC81-5479717OtherEIN