Individual
DR. JERRY WAYNE LONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
O.D
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
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
T02229
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000006948
MEDICARE P-TAN
MO
05
—
310038807
—
MO
05
—
500398706
—
MO
01
—
990001270
GROUP NUMBER
MO
Enumeration date
02/22/2006
Last updated
07/03/2014
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