Provider Demographics
NPI:1518207604
Name:JAMES T. LONG, M.D., PH.D., INC.
Entity Type:Organization
Organization Name:JAMES T. LONG, M.D., PH.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:310-395-7392
Mailing Address - Street 1:650 MORENO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4831
Mailing Address - Country:US
Mailing Address - Phone:310-395-7392
Mailing Address - Fax:310-394-7902
Practice Address - Street 1:650 MORENO AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4831
Practice Address - Country:US
Practice Address - Phone:310-395-7392
Practice Address - Fax:310-394-7902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG190162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19016OtherMEDICARE PTAN
CAG19016OtherMEDICARE PTAN