Provider Demographics
NPI:1174649727
Name:YOCUM, GLENN DAVID (DPM)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:DAVID
Last Name:YOCUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:D
Other - Last Name:YOCUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:5407 17TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3818
Mailing Address - Country:US
Mailing Address - Phone:206-784-2670
Mailing Address - Fax:206-784-1590
Practice Address - Street 1:5407 17TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3818
Practice Address - Country:US
Practice Address - Phone:206-784-2670
Practice Address - Fax:206-784-1590
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000223213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG000105970OtherPTAN
WA00528OtherBLUE CROSS BLUE SHIELD
WAYO0026OtherREGENCE BLUE SHIELD
WA1144401Medicaid
WA0281540001Medicare NSC
WA00528OtherBLUE CROSS BLUE SHIELD