Provider Demographics
NPI:1093754202
Name:DELONG, GREGORY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:DELONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-975-0406
Mailing Address - Fax:407-975-0407
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-975-0406
Practice Address - Fax:407-975-0407
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82519207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276118100Medicaid
FL28852OtherBLUE CROSS BLUE SHIELD
FL28852ZMedicare ID - Type Unspecified
FL276118100Medicaid