Provider Demographics
NPI:1568405884
Name:LONG, JILDA EDEAN (OD)
Entity Type:Individual
Prefix:
First Name:JILDA
Middle Name:EDEAN
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JILDA
Other - Middle Name:EDEAN
Other - Last Name:BARKSDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4251 TWIN MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-1021
Mailing Address - Country:US
Mailing Address - Phone:540-875-8036
Mailing Address - Fax:888-840-8937
Practice Address - Street 1:22 CAMPBELL AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24011
Practice Address - Country:US
Practice Address - Phone:540-982-7890
Practice Address - Fax:540-982-7891
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9237674Medicaid
VA542036583OtherUNITED HEALTH CARE
VA277658OtherANTHEM
2119121OtherCIGNA
VA9237674Medicaid