Provider Demographics
NPI:1780020255
Name:LONG, BOBBY (IDC)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS STERRET DDG-104
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96678-1310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS STERRET DDG-104
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96678-1310
Practice Address - Country:US
Practice Address - Phone:208-515-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710-1002XOtherIDC