Provider Demographics
NPI:1629117510
Name:LONG, STEPHEN E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-888-5665
Practice Address - Fax:417-841-0108
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR6H16207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
AR81453OtherARK BLUE SHIELD
MO1629117510Medicaid
AR138827001Medicaid
MO173098OtherMO BLUE SHIELD
AR81453OtherARK BLUE SHIELD
MO1629117510Medicaid