Provider Demographics
NPI:1194861328
Name:LONG, ROBERT W
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 COMMONWEALTH BLVD W STE 108
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1841
Mailing Address - Country:US
Mailing Address - Phone:276-638-4461
Mailing Address - Fax:
Practice Address - Street 1:240 COMMONWEALTH BLVD W STE 108
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1841
Practice Address - Country:US
Practice Address - Phone:276-638-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101 002062156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician