Provider Demographics
NPI:1740228683
Name:LONGDON, KELLIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:ANN
Last Name:LONGDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:2402 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 106, BLDG. 1
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243
Mailing Address - Country:US
Mailing Address - Phone:941-355-4411
Mailing Address - Fax:941-355-5511
Practice Address - Street 1:2402 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 106, BLDG. 1
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243
Practice Address - Country:US
Practice Address - Phone:941-355-4411
Practice Address - Fax:941-355-5511
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97009207R00000X
TXP3920207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347292001Medicaid
FL276635300Medicaid
TX8EA296OtherBCBS
TXP01411678Medicare UPIN
G51948Medicare UPIN
TX368167ZG6FMedicare PIN
FLAB660ZMedicare PIN