Provider Demographics
NPI:1174622997
Name:LONG, WILLIAM FREDERICK (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:FREDERICK
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:8001 NATURAL BRIGDE RD
Mailing Address - Street 2:MARIALLAC HALL
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121
Mailing Address - Country:US
Mailing Address - Phone:314-516-5987
Mailing Address - Fax:314-516-5507
Practice Address - Street 1:11 CHARLESTOWNE PLAZA
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303
Practice Address - Country:US
Practice Address - Phone:636-441-5585
Practice Address - Fax:636-441-5910
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOT02270152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U75811Medicare UPIN