Provider Demographics
NPI:1770512170
Name:LONGDON, CHARLES A (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:LONGDON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 HALIGUS RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9553
Mailing Address - Country:US
Mailing Address - Phone:224-654-0100
Mailing Address - Fax:224-654-0105
Practice Address - Street 1:10400 HALIGUS RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9553
Practice Address - Country:US
Practice Address - Phone:224-654-0100
Practice Address - Fax:224-654-0105
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44365-021207P00000X
IL036109417207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43498200Medicaid
WI930121753OtherMEDICARE RAILROAD
WI930123615OtherMEDICARE RAILROAD
WIP00153529OtherMEDICARE RAILROAD
H26384Medicare UPIN
WI0108-01400Medicare ID - Type Unspecified
WI43498200Medicaid
WI0040-32350Medicare ID - Type Unspecified