Provider Demographics
NPI:1861503617
Name:LONG, ANDRE (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 MONROE HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4127
Mailing Address - Country:US
Mailing Address - Phone:318-640-8803
Mailing Address - Fax:318-640-8836
Practice Address - Street 1:3636 MONROE HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4127
Practice Address - Country:US
Practice Address - Phone:318-640-8803
Practice Address - Fax:318-640-8836
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA961-193T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist