Basic Information
| Provider Information | |||||||||
| NPI: | 1437531423 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVALOS | ||||||||
| FirstName: | LONG | ||||||||
| MiddleName: | FU | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452061785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453694 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 HIGHLAND AVE | ||||||||
| Address2: | 2ND FLOOR, HOXWORTH BLDG | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135844061 | ||||||||
| FaxNumber: | 5135843349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301117424 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.