Provider Demographics
NPI:1972500221
Name:LONG, MARY INGRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:INGRAM
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:114 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5725
Mailing Address - Country:US
Mailing Address - Phone:318-354-9348
Mailing Address - Fax:318-354-9269
Practice Address - Street 1:114 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5725
Practice Address - Country:US
Practice Address - Phone:318-354-9348
Practice Address - Fax:318-354-9269
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022285207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1494666Medicaid
LA4A767Medicare ID - Type Unspecified
LA1494666Medicaid
LA110226545Medicare PIN