Organization
DRJERRY W LONG OPTOMETRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JERRY W LONG OD (OWNER)
(573) 785-8476
Entity
Organization
Contact information
Practice address
213 N BROADWAY ST, POPLAR BLUFF, MO 63901-5135
(573) 785-8476
(573) 785-8477
Mailing address
213 N BROADWAY ST, POPLAR BLUFF, MO 63901-5135
(573) 785-8476
(573) 785-8477
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
T02229
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
310038807
—
MO
01
—
990001270
MEDICARE PTAN
—
Enumeration date
01/05/2015
Last updated
01/05/2015
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