Provider Demographics
NPI:1053519520
Name:LONG, AMANDA D (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:160 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1307
Mailing Address - Country:US
Mailing Address - Phone:317-773-4482
Mailing Address - Fax:317-770-3796
Practice Address - Street 1:160 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1307
Practice Address - Country:US
Practice Address - Phone:317-773-4482
Practice Address - Fax:317-770-3796
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003462A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232710DMedicare PIN