Provider Demographics
NPI:1225145014
Name:GLENNON, JOSEPH R III (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:GLENNON
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 KEMPTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-1503
Mailing Address - Country:US
Mailing Address - Phone:508-997-3222
Mailing Address - Fax:508-997-6848
Practice Address - Street 1:1212 KEMPTON ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-1503
Practice Address - Country:US
Practice Address - Phone:508-997-3222
Practice Address - Fax:508-997-6848
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2169152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0318515Medicaid
MA0481020001OtherSDMEA
MA059058Medicare ID - Type Unspecified
MA0318515Medicaid