Active NPI
Jerry Wayne Long, O.D
- Optometrist
- Poplar Bluff, MO
National Provider Identifier
1144295197
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- T02229
- Practice address
- 213 N Broadway St
Poplar Bluff, MO 63901-5135 - Phone
- (573) 785-8476
- Fax
- (573) 785-8477
- NPI assigned
- Feb 22, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| 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 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 310038807 | Medicaid | MO | |
| 000006948 | Other | MO | MEDICARE P-TAN |
| 500398706 | Medicaid | MO | |
| 990001270 | Other | MO | GROUP NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| T02229 | MO | MD | Optometrist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Drjerry W Long Optometry | Optometrist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Optometrist
- Poplar Bluff, MO
- NPI 1013305721
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1140566400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1404345600000",
"number": "1144295197",
"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"
},
{
"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": {
"last_name": "LONG",
"first_name": "JERRY",
"middle_name": "WAYNE",
"name_prefix": "Dr.",
"credential": "O.D",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-02-22",
"last_updated": "2014-07-03",
"status": "A"
},
"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": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE P-TAN",
"identifier": "000006948",
"state": "MO"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "500398706",
"state": "MO"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "GROUP NUMBER",
"identifier": "990001270",
"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 Jul 3, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.