Provider Demographics
NPI:1073794921
Name:DAVIS, GLENN M (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:DAVIS
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 1:2304 WESVILL CT
Mailing Address - Street 2:# 360
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-2973
Mailing Address - Country:US
Mailing Address - Phone:919-785-1220
Mailing Address - Fax:919-785-1220
Practice Address - Street 1:2304 WESVILL CT
Practice Address - Street 2:# 360
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2973
Practice Address - Country:US
Practice Address - Phone:919-785-1220
Practice Address - Fax:919-785-1220
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927438Medicaid
NC205780DMedicare PIN
NCC83463Medicare UPIN