Provider Demographics
NPI:1114578804
Name:BAO, DELONG (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DELONG
Middle Name:
Last Name:BAO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 SUGAREE AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1567
Mailing Address - Country:US
Mailing Address - Phone:917-517-7308
Mailing Address - Fax:
Practice Address - Street 1:2727 EXPOSITION BLVD STE 105
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-1227
Practice Address - Country:US
Practice Address - Phone:512-478-6419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist