1811979511 NPI number — BRIAN LONGENDYKE D.O.

Table of content: BRIAN LONGENDYKE D.O. (NPI 1811979511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811979511 NPI number — BRIAN LONGENDYKE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONGENDYKE
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811979511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4790 BARKLEY CIR
Provider Second Line Business Mailing Address:
BLDG A
Provider Business Mailing Address City Name:
FT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-7543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-275-8882
Provider Business Mailing Address Fax Number:
239-275-6304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4790 BARKLEY CIR
Provider Second Line Business Practice Location Address:
BLDG A
Provider Business Practice Location Address City Name:
FT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-7543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-275-8882
Provider Business Practice Location Address Fax Number:
239-275-6304
Provider Enumeration Date:
11/17/2005

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: 207RG0100X , with the licence number:  FLOS0006673 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1811979511 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 205926 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 374229600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80842 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9591507 . This is a "GHI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 100005455 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0971761 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1131942 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4376307 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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