Provider Demographics
NPI:1831119189
Name:LONG, VANDANA R (MD)
Entity Type:Individual
Prefix:
First Name:VANDANA
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 OGLETOWN STANTON RD
Mailing Address - Street 2:MEDICAL ARTS PAVILLION
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2067
Mailing Address - Country:US
Mailing Address - Phone:302-283-3300
Mailing Address - Fax:302-283-3321
Practice Address - Street 1:71 OMEGA DR # D
Practice Address - Street 2:OMEGA PROFESSIONAL CENTER
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2063
Practice Address - Country:US
Practice Address - Phone:302-283-3300
Practice Address - Fax:302-283-3321
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10008041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000146802Medicaid
DEH68726Medicare UPIN
DE0000146802Medicaid