Provider Demographics
NPI:1649231457
Name:LONG, PAUL R (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1155 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7906
Practice Address - Country:US
Practice Address - Phone:570-820-6113
Practice Address - Fax:570-808-6349
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-06-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD019504E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000737850Medicaid
C31715Medicare UPIN