Provider Demographics
NPI:1790725349
Name:LONG, THOMAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:APC-10
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-7959
Mailing Address - Fax:401-444-7144
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:APC-10
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-7959
Practice Address - Fax:401-444-7144
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD06768207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7002204Medicaid
RI7002204Medicaid