Basic Information
| Provider Information | |||||||||
| NPI: | 1902990518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGO | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 W UNIVERSITY AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT - NCWY | ||||||||
| City: | URBANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173262856 | ||||||||
| Practice Location | |||||||||
| Address1: | 17575 WICKER WAY | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925049563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517809389 | ||||||||
| FaxNumber: | 9517809389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | G59848 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
No ID Information.