Provider Demographics
NPI:1376534917
Name:LONG, JACK CALHOUN (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CALHOUN
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:CALHOUN SCOTT
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8240 N MOPAC EXPY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8869
Mailing Address - Country:US
Mailing Address - Phone:512-687-1950
Mailing Address - Fax:
Practice Address - Street 1:1900 SCENIC DR STE 1114
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7724
Practice Address - Country:US
Practice Address - Phone:512-248-2200
Practice Address - Fax:512-248-1950
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7435174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126196801Medicaid
TX86X712Medicare ID - Type Unspecified
TX126196801Medicaid