Provider Demographics
NPI:1487756763
Name:LONG, DOUGLAS G (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:G
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-229-5600
Mailing Address - Fax:850-475-4781
Practice Address - Street 1:3801 E HIGHWAY 98
Practice Address - Street 2:ER
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5318
Practice Address - Country:US
Practice Address - Phone:850-229-5600
Practice Address - Fax:850-475-4781
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD39082Medicaid
AKK0000ZGBJVMedicare ID - Type UnspecifiedPRACTICE GROUP NUMBER
AKK150628Medicare PIN
FLCZ628ZMedicare PIN
AKD03805Medicare UPIN