Provider Demographics
NPI:1326143959
Name:LONG, JEROME MYRON (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:MYRON
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 1:1100 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1944
Mailing Address - Country:US
Mailing Address - Phone:479-444-5016
Mailing Address - Fax:479-587-5980
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1944
Practice Address - Country:US
Practice Address - Phone:479-444-5016
Practice Address - Fax:479-587-5980
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WYTL4463207R00000X
OK16355207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine