Provider Demographics
NPI:1235576356
Name:LONG, SAMUEL EVERETTE III (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:EVERETTE
Last Name:LONG
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RHETT
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6210 E HWY 290 STE 420
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3816 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7048
Practice Address - Country:US
Practice Address - Phone:512-443-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9853208600000X
TXBP10046919208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX402015802Medicaid
TX402015801Medicaid