Provider Demographics
NPI:1821062704
Name:LONG, JOHN A JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:LONG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:10810 CONNECTICUT AVE
Practice Address - Street 2:KAISER PERMANENTE KENSINGTON MEDICAL CENTER
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:301-929-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010318142085R0202X
MDD222992085R0202X
DCMD332422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7200617Medicaid
A45625Medicare UPIN
VA000N3V18Medicare ID - Type Unspecified