Provider Demographics
NPI:1023016615
Name:GRAYBEAL, GLENN E (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:GRAYBEAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SUSSEX AVE
Mailing Address - Street 2:PO BOX 929
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1853
Mailing Address - Country:US
Mailing Address - Phone:302-422-3377
Mailing Address - Fax:302-422-9580
Practice Address - Street 1:1 SUSSEX AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1853
Practice Address - Country:US
Practice Address - Phone:302-422-3377
Practice Address - Fax:302-422-9580
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002212208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000049201Medicaid
441731G83Medicare ID - Type Unspecified
DE0000049201Medicaid