Provider Demographics
NPI:1538149398
Name:LONG, JAMES T (MD PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:LONG
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
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Mailing Address - Street 1:650 MORENO AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:310-395-7392
Mailing Address - Fax:310-394-7902
Practice Address - Street 1:650 MORENO AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049
Practice Address - Country:US
Practice Address - Phone:310-395-7392
Practice Address - Fax:310-394-7902
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG190162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A40483Medicare UPIN
CAG19016Medicare ID - Type Unspecified