Provider Demographics
NPI:1700855186
Name:LONGO, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:LONGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 DELHI ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6320
Mailing Address - Country:US
Mailing Address - Phone:563-557-9111
Mailing Address - Fax:563-589-4046
Practice Address - Street 1:1515 DELHI ST
Practice Address - Street 2:STE 100
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6320
Practice Address - Country:US
Practice Address - Phone:563-557-9111
Practice Address - Fax:563-589-4046
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA20324207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0152744Medicaid
WI30225800Medicaid
IA0152744Medicaid
15274Medicare PIN