Provider Demographics
NPI:1871603613
Name:LONG, DAVID ALLEN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1615 PASADENA AVE SO
Mailing Address - Street 2:250
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707
Mailing Address - Country:US
Mailing Address - Phone:727-381-7727
Mailing Address - Fax:727-381-8229
Practice Address - Street 1:7035 CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-7508
Practice Address - Country:US
Practice Address - Phone:727-381-7727
Practice Address - Fax:727-381-8229
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2020-02-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME44760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044825700Medicaid
FL110199725Medicare PIN
FL044825700Medicaid
FL62592BMedicare PIN
D65384Medicare UPIN
FL930103702Medicare PIN