Provider Demographics
NPI:1871726562
Name:JAMES A. LONG, II O.D. INC
Entity type:Organization
Organization Name:JAMES A. LONG, II O.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONG
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:260-484-2720
Mailing Address - Street 1:1221 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5887
Mailing Address - Country:US
Mailing Address - Phone:260-448-4272
Mailing Address - Fax:260-471-3488
Practice Address - Street 1:1221 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5887
Practice Address - Country:US
Practice Address - Phone:260-484-2720
Practice Address - Fax:260-471-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001507332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100280880AMedicaid
INT35278Medicare UPIN
IN100280880AMedicaid
IN0259940001Medicare NSC