Basic Information
| Provider Information | |||||||||
| NPI: | 1639326721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | ALISSA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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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 | 152W00000X | I3-0001342 | DE | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | I3-0001342 | 01 | DE | DE STATE LICENSE | OTHER | 1639326721 | 01 | DE | INDIVIDUAL NPI | OTHER | 11895550 | 01 | DE | CAQH ID | OTHER | 1245251313 | 01 | DE | MEDICARE GROUP NPI | OTHER | 802115H16 | 01 | MEDICARE GRP MEMBER PTAN | OTHER | G00016 | 01 | MEDICARE GRP PTAN | OTHER | P00947088 | 01 | DE | PALMETTO GBA RR MEDICARE PTAN | OTHER |