Provider Demographics
NPI:1174629885
Name:GLODENER, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GLODENER
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 1:1845 LOCKEWAY DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5936
Mailing Address - Country:US
Mailing Address - Phone:770-343-9112
Mailing Address - Fax:
Practice Address - Street 1:1845 LOCKEWAY DR
Practice Address - Street 2:SUITE 404
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-5936
Practice Address - Country:US
Practice Address - Phone:770-343-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000630759DMedicaid
F75371Medicare UPIN
GA000630759DMedicaid