Provider Demographics
NPI:1932278090
Name:DE LONG, AMY (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:DE LONG
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:DU BRAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:S2845 WHITE EAGLE LANE
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913
Mailing Address - Country:US
Mailing Address - Phone:608-355-1240
Mailing Address - Fax:608-356-6347
Practice Address - Street 1:S2845 WHITE EAGLE LANE
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913
Practice Address - Country:US
Practice Address - Phone:608-355-1240
Practice Address - Fax:608-356-6347
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34508300Medicaid
WI0012OtherWPS STATE PART B
WI0012Medicare ID - Type Unspecified
WI34508300Medicaid