Provider Demographics
NPI:1003887688
Name:NYDAM, GLEN D (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:D
Last Name:NYDAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N SANBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2449
Mailing Address - Country:US
Mailing Address - Phone:605-996-2537
Mailing Address - Fax:605-996-0500
Practice Address - Street 1:305 N SANBORN BLVD
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2449
Practice Address - Country:US
Practice Address - Phone:605-996-2537
Practice Address - Fax:605-996-0500
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD20048OtherSANFORD HEALTH PLAN
SD9170527OtherDAKOTACARE
SD9203192Medicaid
SD0006936OtherWELLMARK BCBS
SD230048OtherMIDLANDS CHOICE
SD9203190Medicaid
SD0325070001Medicare NSC
SD410043407Medicare PIN
SDS6936Medicare PIN
SD20048OtherSANFORD HEALTH PLAN
SDS6983Medicare PIN