Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | J6551 | TX |
NPI | 1386676542 |
---|---|
Provider Name | Dr. Michael David Long |
First Address | Lubbock, TX 79424-3671 |
Second Address | Lubbock, TX 79410-1219 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2006 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
046852201 | (05) | TX |
G61527 | (02) | TX |