Provider Demographics
NPI:1568758688
Name:LONG, KEVAN HEATH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVAN
Middle Name:HEATH
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3635 VISTA AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-268-7133
Mailing Address - Fax:
Practice Address - Street 1:RAF LAKENHEATH 48 MDG/SGHC
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09464-5115
Practice Address - Country:US
Practice Address - Phone:163-852-8124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE27546207Q00000X
IL125-060368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine