Provider Demographics
NPI:1073532693
Name:GOLDRING, GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:GOLDRING
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 1:106 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2138
Mailing Address - Country:US
Mailing Address - Phone:662-562-5500
Mailing Address - Fax:662-562-0600
Practice Address - Street 1:106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2138
Practice Address - Country:US
Practice Address - Phone:662-562-5500
Practice Address - Fax:662-562-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN673152WC0802X, 152W00000X
MS468152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087885Medicaid
MS64-0616130OtherHUMANA GOLD CHOICE
MST21021Medicare UPIN
MS560945699Medicare PIN
MS0392120001Medicare NSC