Provider Demographics
NPI:1568468569
Name:LONGSDORF, KATHERINE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:LONGSDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3547
Mailing Address - Country:US
Mailing Address - Phone:419-281-5575
Mailing Address - Fax:419-289-1677
Practice Address - Street 1:2111 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3547
Practice Address - Country:US
Practice Address - Phone:419-281-5575
Practice Address - Fax:419-289-1677
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350-82781-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2445349Medicaid
OHLO4127551Medicare PIN
OHP01292424Medicare PIN
OH2445349Medicaid
OHH159340Medicare PIN