Provider Demographics
NPI:1912004466
Name:LONGENECKER, ELWOOD N (MD)
Entity Type:Individual
Prefix:
First Name:ELWOOD
Middle Name:N
Last Name:LONGENECKER
Suffix:
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-233-4400
Mailing Address - Fax:801-233-4410
Practice Address - Street 1:2000 SOUTH 900 EAST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105
Practice Address - Country:US
Practice Address - Phone:801-464-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2007-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30831491205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005586716Medicare PIN
UT005806006Medicare PIN
UT005569115Medicare PIN
UT006985017Medicare PIN
UT005584211Medicare PIN
UT005587615Medicare PIN
UT005548882Medicare PIN
UT005549807Medicare PIN
UT005583305Medicare PIN