Provider Demographics
NPI:1184726267
Name:LONG, DARRELL PAUL (DPM)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:PAUL
Last Name:LONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 W ROBB AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801
Mailing Address - Country:US
Mailing Address - Phone:419-225-4176
Mailing Address - Fax:419-225-4069
Practice Address - Street 1:1134 W ROBB AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801
Practice Address - Country:US
Practice Address - Phone:419-225-4176
Practice Address - Fax:419-225-4069
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002205213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9227871Medicare ID - Type Unspecified
T80777Medicare UPIN