Provider Demographics
NPI:1285641449
Name:LONG, ROGER KENJI (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:KENJI
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:513 PARNASSUS AVE # S672
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0434
Mailing Address - Country:US
Mailing Address - Phone:415-476-0750
Mailing Address - Fax:415-476-8214
Practice Address - Street 1:513 PARNASSUS AVE # S672
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0434
Practice Address - Country:US
Practice Address - Phone:415-476-0750
Practice Address - Fax:415-476-8214
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74233207RE0101X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism