Provider Demographics
NPI:1639326721
Name:LONG, ALISSA R (OD)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-5861
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:885 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4158
Practice Address - Country:US
Practice Address - Phone:302-734-5861
Practice Address - Fax:302-734-1921
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEI3-0001342OtherDE STATE LICENSE
DE1639326721OtherINDIVIDUAL NPI
DE11895550OtherCAQH ID
DE1245251313OtherMEDICARE GROUP NPI
802115H16OtherMEDICARE GRP MEMBER PTAN
G00016OtherMEDICARE GRP PTAN
DEP00947088OtherPALMETTO GBA RR MEDICARE PTAN