Provider Demographics
NPI:1770602302
Name:LONG, JEFFREY MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
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 1:7374 S. OLYMPIA AVE.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-1849
Mailing Address - Country:US
Mailing Address - Phone:918-794-2020
Mailing Address - Fax:918-794-2720
Practice Address - Street 1:7374 S. OLYMPIA AVE.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1849
Practice Address - Country:US
Practice Address - Phone:918-794-2020
Practice Address - Fax:918-794-2720
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2341152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200427010AMedicaid
OK100762220AMedicaid
OK200427010AMedicaid
OKOKAAA4082Medicare PIN