Individual
DYLAN JASPER LONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5165 MCCARTY LN, LAFAYETTE, IN 47905-8764
(765) 448-8000
(317) 838-4751
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
01089946A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
264430H21
MEDICARE PTAN
IN
05
—
300074582
—
IN
Enumeration date
04/01/2020
Last updated
08/02/2023
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