Provider Demographics
NPI:1356458806
Name:LONGO, LANCE P (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:P
Last Name:LONGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LANCE
Other - Middle Name:PETER
Other - Last Name:LONGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2598
Practice Address - Country:US
Practice Address - Phone:414-773-4311
Practice Address - Fax:414-454-6747
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI378222084P0800X
MA745702084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32273000Medicaid