Provider Demographics
NPI:1386676542
Name:LONG, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6610 NORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-5909
Mailing Address - Country:US
Mailing Address - Phone:806-787-9111
Mailing Address - Fax:
Practice Address - Street 1:6012 82ND ST STE 15
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3671
Practice Address - Country:US
Practice Address - Phone:806-749-7933
Practice Address - Fax:806-749-6117
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6551207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046852201Medicaid
TX88950JMedicare ID - Type Unspecified
TX046852201Medicaid
TXG61527Medicare UPIN