Provider Demographics
NPI:1265424303
Name:LONG, LANCE (OD)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 SUITE 108 US 127 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601
Mailing Address - Country:US
Mailing Address - Phone:502-875-3050
Mailing Address - Fax:502-226-4261
Practice Address - Street 1:1303 SUITE 108 US 127 SOUTH
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601
Practice Address - Country:US
Practice Address - Phone:502-875-3050
Practice Address - Fax:502-226-4261
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1460DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000149Medicaid
KYP00217662OtherRR MEDICARE
KY000000351964OtherANTHEM BCBS
KY1460DTOtherOD LICENSE NUMBER
U75253Medicare UPIN
KY000000351964OtherANTHEM BCBS
KY1460DTOtherOD LICENSE NUMBER