Provider Demographics
NPI:1093729584
Name:LONG, MICHAEL JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
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 1:1110 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534
Mailing Address - Country:US
Mailing Address - Phone:608-884-3314
Mailing Address - Fax:608-884-4923
Practice Address - Street 1:1110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534
Practice Address - Country:US
Practice Address - Phone:608-884-3314
Practice Address - Fax:608-884-4923
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38514300Medicaid
WI87878Medicare ID - Type Unspecified
WI38514300Medicaid