Provider Demographics
NPI:1619240868
Name:KENNETH L. LONG, M.D., P.A.
Entity Type:Organization
Organization Name:KENNETH L. LONG, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-392-6081
Mailing Address - Street 1:1305 WONDER WORLD DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7546
Mailing Address - Country:US
Mailing Address - Phone:512-392-6081
Mailing Address - Fax:512-353-7268
Practice Address - Street 1:1305 WONDER WORLD DR
Practice Address - Street 2:SUITE 301
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7546
Practice Address - Country:US
Practice Address - Phone:512-392-6081
Practice Address - Fax:512-353-7268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114353902Medicaid
C18516Medicare UPIN
TX114353902Medicaid