Provider Demographics
NPI:1205213980
Name:LONG, ALEXANDER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JAMES
Last Name:LONG
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 1:7131 E GAGE AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-3862
Mailing Address - Country:US
Mailing Address - Phone:626-833-2156
Mailing Address - Fax:
Practice Address - Street 1:1625 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4201
Practice Address - Country:US
Practice Address - Phone:323-268-8391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56399207P00000X
CAA154017207P00000X, 207Q00000X
WAMD60833909207Q00000X
390200000X
KSET-00355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ033383Medicaid