Basic Information
| Provider Information | |||||||||
| NPI: | 1861471179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | AMERICO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 239 OLD MILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603462608 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 SAYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603462608 | ||||||||
| FaxNumber: | 8603474691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 023666 | CT | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 023666 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086X0206X | 023666 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208C00000X | 023666 | CT | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001236660 | 05 | CT | MEDICAID |