Provider Demographics
NPI:1487718672
Name:LONG, MARSHALL C (DO)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:C
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:118 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2352
Mailing Address - Country:US
Mailing Address - Phone:304-487-7936
Mailing Address - Fax:304-487-7835
Practice Address - Street 1:118 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-487-7936
Practice Address - Fax:304-487-7835
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052039000Medicaid
WV0561804Medicare PIN
WVE05960Medicare UPIN