1093960643 NPI number — ALEDA A. LONGWELL MD

Table of content: ALEDA A. LONGWELL MD (NPI 1093960643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093960643 NPI number — ALEDA A. LONGWELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONGWELL
Provider First Name:
ALEDA
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACOBS
Provider Other First Name:
ALEDA
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093960643
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 ROSE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94526-3320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-838-4363
Provider Business Mailing Address Fax Number:
925-838-4545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 EL CAPITAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94526-6258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-838-4363
Provider Business Practice Location Address Fax Number:
925-838-4545
Provider Enumeration Date:
11/24/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  A86547 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0101X , with the licence number: A86547 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CB368 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BJ276Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".