Provider Demographics
NPI:1184799223
Name:LONGO, STACEY LEE (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:LONGO
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 1:3600 ROUTE 66 FL 3
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2645
Mailing Address - Country:US
Mailing Address - Phone:732-807-0877
Mailing Address - Fax:201-751-1680
Practice Address - Street 1:2 CORBETT WAY
Practice Address - Street 2:PATHOLOGY SOLULTIONS 2ND FLOOR
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2263
Practice Address - Country:US
Practice Address - Phone:732-389-5200
Practice Address - Fax:732-389-5299
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67626207ZP0102X
NJ25MA06762600207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8069204Medicaid
NJH08465Medicare UPIN
NJ8069204Medicaid
NJ094404Medicare PIN