Provider Demographics
NPI:1427183672
Name:LONGAKER, MICHAEL THORNTON (MD MBA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THORNTON
Last Name:LONGAKER
Suffix:
Gender:M
Credentials:MD MBA
Other - Prefix:
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Mailing Address - Street 1:55 SHEARER DR
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-3935
Mailing Address - Country:US
Mailing Address - Phone:650-365-4838
Mailing Address - Fax:
Practice Address - Street 1:257 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5101
Practice Address - Country:US
Practice Address - Phone:650-736-1707
Practice Address - Fax:650-736-1705
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG57362208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G573620Medicaid
F46141Medicare UPIN
CA00G573620Medicaid