Provider Demographics
NPI:1144319062
Name:LONG, DENNIS R (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:ROBERT
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:45280 SEELEY DRIVE
Mailing Address - Street 2:3RD FLOOR STE. 365
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253
Mailing Address - Country:US
Mailing Address - Phone:760-610-7300
Mailing Address - Fax:760-610-7301
Practice Address - Street 1:45280 SEELEY DR FL 3
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-6834
Practice Address - Country:US
Practice Address - Phone:760-610-7300
Practice Address - Fax:760-610-7301
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50631Medicare UPIN
CACB225767Medicare PIN