Provider Demographics
NPI:1023067055
Name:LONG, WILLIAM T (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
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:
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Mailing Address - Street 1:1300 N VERMONT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6061
Mailing Address - Country:US
Mailing Address - Phone:323-913-4300
Mailing Address - Fax:
Practice Address - Street 1:1300 N VERMONT AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6061
Practice Address - Country:US
Practice Address - Phone:323-913-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60239207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G602390Medicaid
CA00G602390Medicaid
CAHI463AMedicare PIN
CAG60239AMedicare PIN