Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | 4014 | TX |
Y | 213ER0200X | Radiology | 4014 | TX |
NPI | 1316094659 |
---|---|
Provider Name | Robert Jeffery Longenecker |
First Address | Irving, TX 75061-9396 |
Second Address | Irving, TX 75061-9396 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2007 |
Last Update Date | 15/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
601416 | (02) | TX |