Provider Demographics
NPI:1730101759
Name:LONGSHORE, ROBERT THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THEODORE
Last Name:LONGSHORE
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 1:2546 KEARNEY COURT
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2180
Mailing Address - Country:US
Mailing Address - Phone:859-344-8116
Mailing Address - Fax:
Practice Address - Street 1:870 US HWY 42 W
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:KY
Practice Address - Zip Code:41095-9323
Practice Address - Country:US
Practice Address - Phone:859-567-1591
Practice Address - Fax:859-567-1592
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY12488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64124886Medicaid
C73234Medicare UPIN