Provider Demographics
NPI:1013112283
Name:HUYNH, LONG HA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:HA
Last Name:HUYNH
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:LONG
Other - Middle Name:HA
Other - Last Name:HUYNH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-549-0752
Mailing Address - Fax:618-529-0449
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0449
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD600854844207L00000X
IL036149496207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMULTI SPECIALTY GROUP PTAN