Provider Demographics
NPI:1306409545
Name:LONGMIRE, FALLON (MD)
Entity Type:Individual
Prefix:DR
First Name:FALLON
Middle Name:
Last Name:LONGMIRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-2933
Mailing Address - Country:US
Mailing Address - Phone:727-310-0925
Mailing Address - Fax:727-498-5470
Practice Address - Street 1:901 22ND AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-2933
Practice Address - Country:US
Practice Address - Phone:727-310-0925
Practice Address - Fax:727-498-5470
Is Sole Proprietor?:No
Enumeration Date:2019-04-14
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME160275207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine