Provider Demographics
NPI:1497748628
Name:LONG, GEORGE MADISON JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:MADISON
Last Name:LONG
Suffix:JR
Gender:M
Credentials:DPM
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Mailing Address - Street 1:2401 GODWIN BLVD
Mailing Address - Street 2:STE 1
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8178
Mailing Address - Country:US
Mailing Address - Phone:757-539-2098
Mailing Address - Fax:757-539-5188
Practice Address - Street 1:2401 GODWIN BLVD
Practice Address - Street 2:STE 1
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8178
Practice Address - Country:US
Practice Address - Phone:757-539-2098
Practice Address - Fax:757-539-5188
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-11-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0103000593213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009301879Medicaid
VA009301879Medicaid
VA480000031Medicare PIN