Provider Demographics
NPI:1023087343
Name:LONG, DEANNE (MD)
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:
Last Name:LONG
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 1:540 ARAPEEN DR
Mailing Address - Street 2:STE #110
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1250
Mailing Address - Country:US
Mailing Address - Phone:801-582-4268
Mailing Address - Fax:801-582-4269
Practice Address - Street 1:540 ARAPEEN DR
Practice Address - Street 2:STE 110
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1250
Practice Address - Country:US
Practice Address - Phone:801-582-4268
Practice Address - Fax:801-582-4269
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4752590-1205207PE0004X, 207PE0005X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT608789600OtherW/C
UTD3567Medicaid
UT10552OtherHEALTHY U
UT243586OtherALTIUS
UT47525901202001OtherBC/BS
UTP00396754OtherRAILROAD MEDICARE
UTD3567Medicaid
UT005783104Medicare PIN