Provider Demographics
NPI:1811979511
Name:LONGENDYKE, BRIAN (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LONGENDYKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4790 BARKLEY CIR
Mailing Address - Street 2:BLDG A
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7543
Mailing Address - Country:US
Mailing Address - Phone:239-275-8882
Mailing Address - Fax:239-275-6304
Practice Address - Street 1:4790 BARKLEY CIR
Practice Address - Street 2:BLDG A
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7543
Practice Address - Country:US
Practice Address - Phone:239-275-8882
Practice Address - Fax:239-275-6304
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLFLOS0006673207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1811979511OtherTRICARE
FL205926OtherAVMED
FL374229600Medicaid
FL80842OtherBCBS
FL9591507OtherGHI
FL100005455OtherRAILROAD MEDICARE
FL0971761OtherCIGNA
FL1131942OtherUNITED HEALTHCARE
FL4376307OtherAETNA
FLE55071Medicare UPIN
FL1131942OtherUNITED HEALTHCARE