Provider Demographics
NPI:1972688521
Name:LONG, ERIC WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WILLIAM
Last Name:LONG
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 1:1323 SW SCHAEFFER RD
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-9658
Mailing Address - Country:US
Mailing Address - Phone:503-638-1717
Mailing Address - Fax:503-692-1992
Practice Address - Street 1:1323 SW SCHAEFFER RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9658
Practice Address - Country:US
Practice Address - Phone:503-638-1717
Practice Address - Fax:503-692-1992
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000BHJPRMedicare ID - Type Unspecified
ORC 93171Medicare UPIN