Provider Demographics
NPI:1891894564
Name:LONG, DANIEL J (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
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 1:113 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3129
Mailing Address - Country:US
Mailing Address - Phone:701-663-2020
Mailing Address - Fax:701-667-2057
Practice Address - Street 1:113 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3129
Practice Address - Country:US
Practice Address - Phone:701-663-2020
Practice Address - Fax:701-667-2057
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60231Medicaid
ND60231Medicaid
NDN8838Medicare PIN