Provider Demographics
NPI:1912924432
Name:LONG, THOMAS V (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:V
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11025 WILLOWBRAE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-1495
Mailing Address - Country:US
Mailing Address - Phone:818-205-6523
Mailing Address - Fax:
Practice Address - Street 1:1680 S GARFIELD AVE STE 204
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-5413
Practice Address - Country:US
Practice Address - Phone:818-839-5200
Practice Address - Fax:818-839-5190
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-11-27
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Provider Licenses
StateLicense IDTaxonomies
CAG73457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G734570Medicaid
CA00G734570Medicaid