Provider Demographics
NPI:1083727408
Name:ETZEL, GLENN T (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:T
Last Name:ETZEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 882
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0882
Mailing Address - Country:US
Mailing Address - Phone:435-636-0625
Mailing Address - Fax:435-637-4448
Practice Address - Street 1:230 N HOSPITAL DR
Practice Address - Street 2:SUITE 5
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4221
Practice Address - Country:US
Practice Address - Phone:435-637-9545
Practice Address - Fax:435-637-3423
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT821690231205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000002152Medicare ID - Type Unspecified
C63590Medicare UPIN