Provider Demographics
NPI:1932399730
Name:LONG, MARY C (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:C
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:114 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-2648
Mailing Address - Country:US
Mailing Address - Phone:662-369-2444
Mailing Address - Fax:662-369-7223
Practice Address - Street 1:114 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-2648
Practice Address - Country:US
Practice Address - Phone:662-369-2444
Practice Address - Fax:662-369-7223
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087903Medicaid
MS00087903Medicaid
MS410000324Medicare PIN