Provider Demographics
NPI:1003977364
Name:GRIFFIN, GLYNN (OD)
Entity Type:Individual
Prefix:
First Name:GLYNN
Middle Name:
Last Name:GRIFFIN
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 1:2600 W PLEASANT CROSSING DR STE 60
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8323
Mailing Address - Country:US
Mailing Address - Phone:479-202-4725
Mailing Address - Fax:
Practice Address - Street 1:2600 W PLEASANT CROSSING DR STE 60
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8323
Practice Address - Country:US
Practice Address - Phone:479-202-4725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4001152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAT19560Medicare UPIN
LA4B360CJ07Medicare ID - Type UnspecifiedMEDICARE