Provider Demographics
NPI:1720403553
Name:LONGO, DIANNE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:LONGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 EVERGREEN AVE
Mailing Address - Street 2:APT N2
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2063
Mailing Address - Country:US
Mailing Address - Phone:714-697-8359
Mailing Address - Fax:
Practice Address - Street 1:1319 EVERGREEN AVE
Practice Address - Street 2:APT N2
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2063
Practice Address - Country:US
Practice Address - Phone:714-697-8359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2251P0200X207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine