Provider Demographics
NPI:1073519682
Name:WILENSKY, GLEN R (DPM)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:R
Last Name:WILENSKY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7406 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1817
Mailing Address - Country:US
Mailing Address - Phone:804-262-7153
Mailing Address - Fax:804-262-0104
Practice Address - Street 1:7406 BROOK RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1817
Practice Address - Country:US
Practice Address - Phone:804-262-7153
Practice Address - Fax:804-262-0104
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA 0103000938213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01021914Medicaid
VA172333OtherANTHEM
VA172333OtherANTHEM
U45134Medicare UPIN