Provider Demographics
NPI:1669977104
Name:LONG, ZACHARY JAMES (MD)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:JAMES
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3421 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-3112
Mailing Address - Country:US
Mailing Address - Phone:601-927-8822
Mailing Address - Fax:
Practice Address - Street 1:3245 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3419
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8936
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.156666207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036156666Medicaid
IL036156666OtherSTATE LICENSE