Provider Demographics
NPI:1053389247
Name:LONGABAUGH, JAMES LEE (MD12)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LEE
Last Name:LONGABAUGH
Suffix:
Gender:M
Credentials:MD12
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6309
Mailing Address - Country:US
Mailing Address - Phone:805-544-5567
Mailing Address - Fax:805-544-3265
Practice Address - Street 1:990 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6309
Practice Address - Country:US
Practice Address - Phone:805-544-5567
Practice Address - Fax:805-544-3265
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC-34894207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA-87763Medicare UPIN
CAC34894Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER