Provider Demographics
NPI:1629284369
Name:LONG, JOHN EARL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EARL
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:13690 LONGS LANDING RD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5423
Mailing Address - Country:US
Mailing Address - Phone:904-535-7801
Mailing Address - Fax:904-221-7751
Practice Address - Street 1:13690 LONGS LANDING RD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-5423
Practice Address - Country:US
Practice Address - Phone:904-535-7801
Practice Address - Fax:904-221-7751
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 63156207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine