Provider Demographics
NPI:1083985154
Name:LONG, ROBERT WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 TYLER RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-3305
Mailing Address - Country:US
Mailing Address - Phone:630-584-2070
Mailing Address - Fax:
Practice Address - Street 1:525 TYLER RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-3305
Practice Address - Country:US
Practice Address - Phone:630-584-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-22
Last Update Date:2012-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-075581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine