Provider Demographics
NPI:1972544948
Name:LONGCHAMP, CARLA PRICE (MD)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:PRICE
Last Name:LONGCHAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4305
Mailing Address - Country:US
Mailing Address - Phone:707-459-6861
Mailing Address - Fax:707-459-3057
Practice Address - Street 1:1300 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-7112
Practice Address - Country:US
Practice Address - Phone:707-459-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF85637Medicare UPIN