Provider Demographics
NPI:1821169475
Name:LONGWELL, BILL JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:BILL
Middle Name:JOE
Last Name:LONGWELL
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 1:2417 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501
Mailing Address - Country:US
Mailing Address - Phone:510-752-9063
Mailing Address - Fax:510-752-9050
Practice Address - Street 1:2417 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:510-752-9063
Practice Address - Fax:510-752-9050
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41238207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ46328ZMedicaid
CA00G412380Medicare ID - Type Unspecified
CAZZZ46328ZMedicaid