Provider Demographics
NPI:1558400291
Name:LONG, KUUMBA K (MD)
Entity Type:Individual
Prefix:DR
First Name:KUUMBA
Middle Name:K
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-9244
Practice Address - Street 1:1601 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902
Practice Address - Country:US
Practice Address - Phone:765-453-5696
Practice Address - Fax:765-455-4323
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066913A207W00000X
CAA97642207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA09161OtherPI NUMBER
IN200950820Medicaid
IN000000623704OtherANTHEM PROVIDER NUMBER
INP01173040Medicare PIN
IN000000623704OtherANTHEM PROVIDER NUMBER
CA09161OtherPI NUMBER
IN815500AA4Medicare PIN
INP00803379Medicare PIN
IN160450016Medicare PIN
IN669220007Medicare PIN
CARES000Medicare UPIN
IN200950820Medicaid