Provider Demographics
NPI:1093750317
Name:HERMANN, GLENN HOWARD (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:HOWARD
Last Name:HERMANN
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 1:3416 VIRGINIA AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-2240
Mailing Address - Country:US
Mailing Address - Phone:276-747-4488
Mailing Address - Fax:276-647-7569
Practice Address - Street 1:3416 VIRGINIA AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-2240
Practice Address - Country:US
Practice Address - Phone:276-747-4488
Practice Address - Fax:276-647-7569
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000497152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009231854Medicaid
VA541741479OtherACCORDIA NATIONAL
VA541741479Medicaid
VA910899OtherCOLE
VA541741479OtherALL ALLIANCE PPO
VA040437OtherBLUE CROSS BLUE SHIELD
VA541741479OtherCIGNA HEALTHCARE
VA541741479OtherMAIL HANDLERS BENEFIT
VA541741479OtherAETNA
VA450168OtherCOBINED INSURANCE CO OF A
VA541741479OtherUNITED HEALTH CARE
VA541741479OtherCONSECO HEALTH INSURANCE
VA541741479OtherGAATEWAY/PRIMARY PHYSICAN
VA5674OtherVISION WITH B/C B/S
VA541741479OtherCARILION HEALTH PLANS
VA9615238OtherCIGNA HEALTHCARE
VA541741479OtherAETNA
VA410000873Medicare ID - Type UnspecifiedTRAILBLAZER
VA5674OtherVISION WITH B/C B/S
VA541741479OtherUNITED HEALTH CARE