Provider Demographics
NPI:1083724512
Name:DAVIS, GLENN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
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 1:1510 BOB WHITE BLVD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-4406
Mailing Address - Country:US
Mailing Address - Phone:540-980-1965
Mailing Address - Fax:540-980-0032
Practice Address - Street 1:1510 BOB WHITE BLVD
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-4406
Practice Address - Country:US
Practice Address - Phone:540-980-1965
Practice Address - Fax:540-980-0032
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036189207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010104238Medicaid
VA010126991Medicaid
VA00W320G01Medicare PIN
VA010104238Medicaid
VA010126991Medicaid