Provider Demographics
NPI:1881761948
Name:LONG, JOHN B (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 DANIEL BURNHAM CT
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109
Mailing Address - Country:US
Mailing Address - Phone:415-221-7056
Mailing Address - Fax:415-221-7058
Practice Address - Street 1:1 DANIEL BURNHAM CT
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5455
Practice Address - Country:US
Practice Address - Phone:415-221-7056
Practice Address - Fax:415-221-7058
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG409742086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00080208OtherRR MEDICARE
CA00G792860OtherBLUE CROSS
CA00G409741Medicaid
CA00G792860OtherBLUE SHIELD
CAA48414Medicare UPIN
CA00G409740Medicare PIN
CA00G792860OtherBLUE SHIELD