Provider Demographics
NPI:1629177936
Name:LONG, JEFFREY P (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
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 1:4950 ESSEN LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3738
Mailing Address - Country:US
Mailing Address - Phone:225-215-1311
Mailing Address - Fax:
Practice Address - Street 1:8166 MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3404
Practice Address - Country:US
Practice Address - Phone:985-876-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000382482085R0001X
LA2027532085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1450243Medicaid
LA4N8627290Medicare PIN
A76249Medicare UPIN