Basic Information
| Provider Information | |||||||||
| NPI: | 1285028126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGO-IMEDIO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | ISABEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONGO | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | ISABEL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4037 NW 86TH TER | ||||||||
| Address2: | FOURTH FLOOR | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525941500 | ||||||||
| FaxNumber: | 3525941501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4037 NW 86TH TER | ||||||||
| Address2: | FOURTH FLOOR | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525941500 | ||||||||
| FaxNumber: | 3525941501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2015 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 282851828 | ZZ | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 015478700 | 05 | FL | MEDICAID |