Provider Demographics
NPI:1881030112
Name:WILLIAM T LONG MD INC A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WILLIAM T LONG MD INC A CALIFORNIA PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-913-4300
Mailing Address - Street 1:1300 N VERMONT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6061
Mailing Address - Country:US
Mailing Address - Phone:323-913-4300
Mailing Address - Fax:
Practice Address - Street 1:1300 N VERMONT AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6061
Practice Address - Country:US
Practice Address - Phone:323-913-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG060239207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G602390Medicaid
CAHI463AOtherMEDICARE PTAN
CAHI463AOtherMEDICARE PTAN
CAG60239AMedicare UPIN