Provider Demographics
NPI:1891876462
Name:LONG, ALFRED M JR (OD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:M
Last Name:LONG
Suffix:JR
Gender:M
Credentials:OD
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Mailing Address - Street 1:2645 DALLAS HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:770-422-8002
Mailing Address - Fax:770-422-4618
Practice Address - Street 1:2645 DALLAS HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:770-422-8002
Practice Address - Fax:770-422-4618
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2019-02-25
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Provider Licenses
StateLicense IDTaxonomies
GA1218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCBCSMedicare ID - Type UnspecifiedOD
GAU22423Medicare UPIN
GA41ZCBCSMedicare PIN