Provider Demographics
NPI:1043749872
Name:GLENN, BRADLEY HOLMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:HOLMAN
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRADLEY
Other - Middle Name:KEITH
Other - Last Name:HOLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:85 MAUI LANI PKWY
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2416
Mailing Address - Country:US
Mailing Address - Phone:808-244-5366
Mailing Address - Fax:
Practice Address - Street 1:85 MAUI LANI PKWY
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2416
Practice Address - Country:US
Practice Address - Phone:808-244-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-21314207Q00000X
AZR76084390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program