Provider Demographics
NPI:1568741379
Name:LONG, RACHEL ANNA (DD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNA
Last Name:LONG
Suffix:
Gender:F
Credentials:DD
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:ANNA
Other - Last Name:GRUNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:682-885-3113
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4095
Practice Address - Fax:682-885-7499
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019186208000000X
TXQ72282080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics