Provider Demographics
NPI:1679767263
Name:LONGPHRE, KAORI MIYATA (MD)
Entity Type:Individual
Prefix:DR
First Name:KAORI
Middle Name:MIYATA
Last Name:LONGPHRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21A OAK BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2145
Mailing Address - Country:US
Mailing Address - Phone:336-478-2666
Mailing Address - Fax:
Practice Address - Street 1:705 GREEN VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408
Practice Address - Country:US
Practice Address - Phone:336-272-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600372207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908081Medicaid
NC5908081Medicaid