Basic Information
| Provider Information | |||||||||
| NPI: | 1831119189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | VANDANA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4745 OGLETOWN STANTON RD | ||||||||
| Address2: | MEDICAL ARTS PAVILLION | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022833300 | ||||||||
| FaxNumber: | 3022833321 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 OMEGA DR # D | ||||||||
| Address2: | OMEGA PROFESSIONAL CENTER | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022833300 | ||||||||
| FaxNumber: | 3022833321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 174400000X | C10008041 | DE | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0000146802 | 05 | DE | MEDICAID |