Provider Demographics
NPI:1275653560
Name:LONG, MICHAEL L (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1436 OAKCREEK LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8729
Mailing Address - Country:US
Mailing Address - Phone:760-727-2311
Mailing Address - Fax:760-439-8271
Practice Address - Street 1:3621 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4522
Practice Address - Country:US
Practice Address - Phone:760-757-1144
Practice Address - Fax:760-721-7701
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA5300T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5300TOtherCALIFORNIA STATE LICENSE