Provider Demographics
NPI:1851477079
Name:LONGEST, TOM B JR (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:B
Last Name:LONGEST
Suffix:JR
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:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:BRUCE
Mailing Address - State:MS
Mailing Address - Zip Code:38915
Mailing Address - Country:US
Mailing Address - Phone:662-983-3222
Mailing Address - Fax:662-983-2006
Practice Address - Street 1:128 PUBLIC SQUARE
Practice Address - Street 2:
Practice Address - City:BRUCE
Practice Address - State:MS
Practice Address - Zip Code:38915
Practice Address - Country:US
Practice Address - Phone:662-983-3222
Practice Address - Fax:662-983-2006
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010518Medicaid
MS00010518Medicaid
MS080000658Medicare ID - Type Unspecified