Provider Demographics
NPI:1558476275
Name:LONG, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1020 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4141
Mailing Address - Country:US
Mailing Address - Phone:503-581-7412
Mailing Address - Fax:503-581-1095
Practice Address - Street 1:1020 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4141
Practice Address - Country:US
Practice Address - Phone:503-581-7412
Practice Address - Fax:503-581-1095
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10954207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR217943Medicaid
ORR0000WFBHVMedicare ID - Type Unspecified
OR217943Medicaid