NPIMap

Organization Active NPI

Dr Jerry W Long Optometry

  • Optometrist
  • Poplar Bluff, MO
National Provider Identifier
1073719910
Registry record updated Jan 8, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
T02229 Issued in MO
Legal business name
DR JERRY W LONG OPTOMETRY
Practice address
213 N Broadway St
Poplar Bluff, MO 63901-5135
Phone
(573) 785-8476
Fax
(573) 785-8477
NPI assigned
Jun 26, 2007
Last updated
Jan 8, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 8, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jerry Wayne Long, ODNPI 1144295197
Title
Owner Optomotrist
Phone
(573) 785-8476

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X T02229 MO Primary

Addresses

Primary practice location

213 N Broadway St
Poplar Bluff, MO 63901-5135

Mailing address

213 N Broadway St
Poplar Bluff, MO 63901-5135
Phone (573) 785-8476

Other identifiers 2

IdentifierTypeStateIssuer
310038807MedicaidMO
500398706MedicaidMO

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1182816000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1420675200000",
    "number": "1073719910",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "213 N BROADWAY ST",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639015135",
            "telephone_number": "573-785-8476",
            "fax_number": "573-785-8477"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "213 N BROADWAY ST",
            "city": "POPLAR BLUFF",
            "state": "MO",
            "postal_code": "639015135",
            "telephone_number": "573-785-8476",
            "fax_number": "573-785-8477"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DR JERRY W LONG OPTOMETRY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-26",
        "last_updated": "2015-01-08",
        "status": "A",
        "authorized_official_last_name": "LONG",
        "authorized_official_first_name": "JERRY",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "OWNER      OPTOMOTRIST",
        "authorized_official_telephone_number": "573-785-8476",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "MO",
            "license": "T02229",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "310038807",
            "state": "MO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500398706",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Poplar Bluff, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.