Provider Demographics
NPI:1043288657
Name:GLEMBOCKI, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:GLEMBOCKI
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 1:11130 N TATUM BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1662
Mailing Address - Country:US
Mailing Address - Phone:602-494-1817
Mailing Address - Fax:602-494-7103
Practice Address - Street 1:11130 N TATUM BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1662
Practice Address - Country:US
Practice Address - Phone:602-494-1817
Practice Address - Fax:602-494-7103
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30978207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ796766Medicaid
H86547Medicare UPIN
AZ796766Medicaid
75287Medicare ID - Type Unspecified