Provider Demographics
NPI:1831597673
Name:LONG, SAVANNAH FAYE (OD)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:FAYE
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8016
Mailing Address - Country:US
Mailing Address - Phone:304-647-1139
Mailing Address - Fax:304-647-3006
Practice Address - Street 1:1322 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:304-647-5114
Practice Address - Fax:304-647-3006
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4969152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist