Provider Demographics
NPI:1144295197
Name:LONG, JERRY WAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WAYNE
Last Name:LONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:213 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5135
Mailing Address - Country:US
Mailing Address - Phone:573-785-8476
Mailing Address - Fax:
Practice Address - Street 1:213 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5135
Practice Address - Country:US
Practice Address - Phone:573-785-8476
Practice Address - Fax:573-785-8477
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310038807Medicaid
MO000006948OtherMEDICARE P-TAN
MO500398706Medicaid
MO990001270OtherGROUP NUMBER
MO000006948OtherMEDICARE P-TAN