Provider Demographics
NPI:1780687921
Name:LONGA, GERALD J (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:J
Last Name:LONGA
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:PO BOX 1054
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47808-1054
Mailing Address - Country:US
Mailing Address - Phone:812-232-9557
Mailing Address - Fax:812-232-1517
Practice Address - Street 1:1606 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2706
Practice Address - Country:US
Practice Address - Phone:812-232-9557
Practice Address - Fax:812-232-1517
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN858090EMedicare ID - Type Unspecified
INE03942Medicare UPIN