Provider Demographics
NPI:1861694424
Name:HOANG, LONG NGOC (DO)
Entity type:Individual
Prefix:
First Name:LONG
Middle Name:NGOC
Last Name:HOANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2233
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-1376
Mailing Address - Country:US
Mailing Address - Phone:817-781-7237
Mailing Address - Fax:
Practice Address - Street 1:1315 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4404
Practice Address - Country:US
Practice Address - Phone:833-484-6359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87500207Q00000X
TXP5079207PE0005X, 207Q00000X
SC32276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322760Medicaid
SCAA53257951Medicare PIN