Provider Demographics
NPI:1700868585
Name:LONGBOTTOM, WARD G (MD)
Entity Type:Individual
Prefix:
First Name:WARD
Middle Name:G
Last Name:LONGBOTTOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4613
Mailing Address - Country:US
Mailing Address - Phone:813-615-7914
Mailing Address - Fax:813-615-8134
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-615-7914
Practice Address - Fax:813-615-8134
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55322207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050042933OtherRAILROAD MEDICARE
FL052605300Medicaid
FL11848OtherBCBS
FL052605300Medicaid
050042933OtherRAILROAD MEDICARE
E77793Medicare UPIN