Individual
DATA LONGJOHN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1537 STRAIGHT PATH, STE102, WYANDANCH, NY 11798-3414
(631) 253-0270
(631) 253-0273
Mailing address
1537 STRAIGHT PATH, STE102, WYANDANCH, NY 11798-3414
(631) 253-0270
(631) 253-0273
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
211159
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01889129
—
NY
Enumeration date
02/03/2007
Last updated
07/08/2007
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