Provider Demographics
NPI:1114958766
Name:GLASS, PAUL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WAYNE
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:781 LEISURE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8320
Mailing Address - Country:US
Mailing Address - Phone:317-888-6805
Mailing Address - Fax:
Practice Address - Street 1:3725 KENTUCKY AVE
Practice Address - Street 2:STIRLING CLINIC
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-2755
Practice Address - Country:US
Practice Address - Phone:317-856-2300
Practice Address - Fax:317-856-2306
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025735A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC96078Medicare UPIN
IN895030Medicare ID - Type Unspecified