Provider Demographics
NPI:1093960643
Name:LONGWELL, ALEDA A (MD)
Entity Type:Individual
Prefix:
First Name:ALEDA
Middle Name:A
Last Name:LONGWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALEDA
Other - Middle Name:A
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:360 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-3320
Mailing Address - Country:US
Mailing Address - Phone:925-838-4363
Mailing Address - Fax:925-838-4545
Practice Address - Street 1:1320 EL CAPITAN DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-6258
Practice Address - Country:US
Practice Address - Phone:925-838-4363
Practice Address - Fax:925-838-4545
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86547207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB368OtherMEDICARE PTAN
CABJ276ZOtherMEDICARE PTAN