Provider Demographics
NPI:1023638871
Name:LY, LONG (MD)
Entity type:Individual
Prefix:
First Name:LONG
Middle Name:
Last Name:LY
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 1:3193 HOWELL MILL RD NW STE 220
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2100
Mailing Address - Country:US
Mailing Address - Phone:404-350-5777
Mailing Address - Fax:404-350-5755
Practice Address - Street 1:3193 HOWELL MILL RD NW STE 220
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2100
Practice Address - Country:US
Practice Address - Phone:404-350-5777
Practice Address - Fax:404-350-5755
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA99267207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program