Provider Demographics
NPI:1164524823
Name:GLODE, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:GLODE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:EDWARD
Other - Last Name:GLODE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:930 RANGER DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2535
Mailing Address - Country:US
Mailing Address - Phone:307-773-1304
Mailing Address - Fax:
Practice Address - Street 1:1200 E 20TH ST STE A
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3979
Practice Address - Country:US
Practice Address - Phone:307-773-1304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4442A207RC0000X
NE12361207RC0000X
CODR-19261207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYD23571Medicare UPIN