Provider Demographics
NPI:1639326721
Name:LONG, ALISSA R (OD)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1941 LIMESTONE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5400
Mailing Address - Country:US
Mailing Address - Phone:302-998-2333
Mailing Address - Fax:302-998-2982
Practice Address - Street 1:1941 LIMESTONE RD STE 200
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5400
Practice Address - Country:US
Practice Address - Phone:302-998-2333
Practice Address - Fax:302-998-2982
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00016OtherMEDICARE GRP PTAN
DEI3-0001342OtherDE STATE LICENSE
DEP00947088OtherPALMETTO GBA RR MEDICARE PTAN
DE1639326721OtherINDIVIDUAL NPI
DE1245251313OtherMEDICARE GROUP NPI
802115H16OtherMEDICARE GRP MEMBER PTAN
DE11895550OtherCAQH ID