Provider Demographics
NPI:1619085370
Name:LONG, THOMAS N (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:N
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3745
Mailing Address - Country:US
Mailing Address - Phone:940-627-7443
Mailing Address - Fax:940-627-7464
Practice Address - Street 1:1001 W EAGLE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3745
Practice Address - Country:US
Practice Address - Phone:940-627-7443
Practice Address - Fax:940-627-7464
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0565208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX020030286OtherRAILROAD MEDICARE
TX177596001Medicaid
TX177596001Medicaid
TX81Z883Medicare PIN