Provider Demographics
NPI:1821092271
Name:LONGENECKER, STANTON L (MD)
Entity Type:Individual
Prefix:
First Name:STANTON
Middle Name:L
Last Name:LONGENECKER
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 1:11945 SAN JOSE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:2 SHIRCLIFF WAY STE 300
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4753
Practice Address - Country:US
Practice Address - Phone:904-204-5000
Practice Address - Fax:904-204-4000
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49077207X00000X, 207XS0114X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062862000Medicaid
FL200003910OtherRR MEDICARE
FL02225VMedicare PIN
FL02225WMedicare PIN
FL200003910OtherRR MEDICARE
FL02225XMedicare PIN