Provider Demographics
NPI:1861983959
Name:LONGFELLOW, CAMERON TYLER
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:TYLER
Last Name:LONGFELLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 MARKET CENTER BLVD APT 5414
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75207-3496
Mailing Address - Country:US
Mailing Address - Phone:903-253-5538
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7200
Practice Address - Country:US
Practice Address - Phone:214-645-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist