Provider Demographics
NPI:1477685931
Name:LONG, LORI ANN (OD)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-488-2020
Mailing Address - Fax:941-484-2200
Practice Address - Street 1:1800 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4958
Practice Address - Country:US
Practice Address - Phone:941-474-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20540OtherBC/BS FLORIDA
FL20540WOtherMEDICARE
U52894Medicare UPIN
20540BMedicare ID - Type Unspecified