Provider Demographics
NPI:1518027796
Name:LONG, JUDITH JACOLYN (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:JACOLYN
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:L
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602
Mailing Address - Country:US
Mailing Address - Phone:508-799-9691
Mailing Address - Fax:
Practice Address - Street 1:18 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:774-437-5148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine