Provider Demographics
NPI:1801991666
Name:LONGO, PETER JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAMES
Last Name:LONGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:287 NORTHERN BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4717
Mailing Address - Country:US
Mailing Address - Phone:516-482-0360
Mailing Address - Fax:516-482-2436
Practice Address - Street 1:287 NORTHERN BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4717
Practice Address - Country:US
Practice Address - Phone:516-482-0360
Practice Address - Fax:516-482-2436
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155672207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
A63729Medicare UPIN
67D481Medicare ID - Type Unspecified