Provider Demographics
NPI:1689834400
Name:WARREN DAVID. LONG
Entity Type:Organization
Organization Name:WARREN DAVID. LONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-424-8436
Mailing Address - Street 1:2625 LINE AVE
Mailing Address - Street 2:155
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3047
Mailing Address - Country:US
Mailing Address - Phone:318-424-8436
Mailing Address - Fax:318-424-8438
Practice Address - Street 1:2625 LINE AVE
Practice Address - Street 2:155
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3047
Practice Address - Country:US
Practice Address - Phone:318-424-8436
Practice Address - Fax:318-424-8438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02812R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1107948Medicaid
LAB60836Medicare UPIN