Provider Demographics
NPI:1851406243
Name:LONG, MATTHEW THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:718 N GUADALUPE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2260
Mailing Address - Country:US
Mailing Address - Phone:310-936-1856
Mailing Address - Fax:
Practice Address - Street 1:1919 S CATALINA AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5515
Practice Address - Country:US
Practice Address - Phone:310-378-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA2OA8553207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA125774Medicare UPIN