Provider Demographics
NPI:1184675076
Name:LONG, CYNTHIA A (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:STANSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:923 ROSEMOOR DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:923 ROSEMOOR DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5374
Practice Address - Country:US
Practice Address - Phone:817-427-9014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK41312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT4457OtherMEDICARE RAILROAD GROUP PTAN
TXP01657830OtherMEDICARE RAILROAD PTAN
TX158932701Medicaid
TX407426YMZSMedicare PIN
TX8A8454Medicare PIN
TXP00035824Medicare PIN
TXTXB120128Medicare PIN
TXB156437Medicare PIN
TX407426YUAVMedicare PIN
TX158932701Medicaid
TX292521Medicare PIN
TX158932703Medicare PIN
TXP01657830OtherMEDICARE RAILROAD PTAN
TXDT4457OtherMEDICARE RAILROAD GROUP PTAN
E42674Medicare UPIN