Provider Demographics
NPI:1376561910
Name:LONG, JEFFREY CLARKE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CLARKE
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:35 LYON STREET
Mailing Address - City:NAPLES
Mailing Address - State:NY
Mailing Address - Zip Code:14512-0249
Mailing Address - Country:US
Mailing Address - Phone:585-374-2900
Mailing Address - Fax:585-394-2950
Practice Address - Street 1:35 LYON ST
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:NY
Practice Address - Zip Code:14512-9707
Practice Address - Country:US
Practice Address - Phone:585-374-2900
Practice Address - Fax:585-394-2950
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01044480Medicaid
NY157100OtherNYS LICENSE
NY16-1311940OtherTAX ID
NY16-1311940OtherTAX ID
NYC58500Medicare UPIN
NY01044480Medicaid