Provider Demographics
NPI:1164449039
Name:GLANVILLE, PAUL RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RAY
Last Name:GLANVILLE
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 1:21945 HIGHWAY 550
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:CO
Mailing Address - Zip Code:81432-9660
Mailing Address - Country:US
Mailing Address - Phone:970-626-5255
Mailing Address - Fax:
Practice Address - Street 1:21945 HIGHWAY 550
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:CO
Practice Address - Zip Code:81432-9660
Practice Address - Country:US
Practice Address - Phone:970-626-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11814-020207Q00000X
WA29762207Q00000X
CO45104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06437058Medicaid
MS06437058Medicaid