Provider Demographics
NPI:1780718387
Name:LONGWORTH, MAUREEN PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:PATRICIA
Last Name:LONGWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3099 NOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1943
Mailing Address - Country:US
Mailing Address - Phone:907-209-2005
Mailing Address - Fax:907-523-9355
Practice Address - Street 1:3099 NOWELL AVE
Practice Address - Street 2:119 SEWARD ST, SUITE 17
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1943
Practice Address - Country:US
Practice Address - Phone:907-209-2005
Practice Address - Fax:907-523-9355
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKE27917Medicare UPIN