Provider Demographics
NPI:1780021667
Name:LONG, TRISTAN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:MICHAEL
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8808 W STEBBINSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-8877
Mailing Address - Country:US
Mailing Address - Phone:608-295-3011
Mailing Address - Fax:
Practice Address - Street 1:1110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-1328
Practice Address - Country:US
Practice Address - Phone:608-884-3314
Practice Address - Fax:608-884-4923
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3305-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist