Provider Demographics
NPI:1356351043
Name:LONG, JOHN CHARLES JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:LONG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:155 N NOVA RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5138
Mailing Address - Country:US
Mailing Address - Phone:386-672-3111
Mailing Address - Fax:386-672-6532
Practice Address - Street 1:155 N NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5138
Practice Address - Country:US
Practice Address - Phone:386-672-3111
Practice Address - Fax:386-672-6532
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0068137207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32591Medicare ID - Type Unspecified
G62265Medicare UPIN