Provider Demographics
NPI:1255368528
Name:LONG, DOUGLAS M (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:N19W23993 RIDGEVIEW PKWY W STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1031
Mailing Address - Country:US
Mailing Address - Phone:262-547-3352
Mailing Address - Fax:
Practice Address - Street 1:N19W23993 RIDGEVIEW PKWY W STE 100
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1031
Practice Address - Country:US
Practice Address - Phone:262-547-3352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI39703207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00449642OtherRR MEDICARE
WI32443200Medicaid
WI32443200Medicaid
WI46236-0275Medicare PIN
WI01994-0275Medicare PIN