Provider Demographics
NPI:1356317002
Name:LONG, ROBERT LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:909 MAR WALT DR
Practice Address - Street 2:SUITE 1011
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6635
Practice Address - Country:US
Practice Address - Phone:850-863-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0043999208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1193377OtherWELLCARE
FL382563OtherAVMED
FL47173OtherBCBS OF FL
FLP00728665OtherRR MEDICARE
FL160003096Medicare PIN
FL47173OtherBCBS OF FL
FLC78505Medicare UPIN
FL47173Medicare PIN
FL382563OtherAVMED