Provider Demographics
NPI:1235115684
Name:VAHJEN, GLEN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ANDREW
Last Name:VAHJEN
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 1:3200 OLD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-4226
Mailing Address - Country:US
Mailing Address - Phone:706-571-1055
Mailing Address - Fax:
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1064
Practice Address - Fax:706-571-1986
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0558302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D77076Medicare UPIN
GA30BDLWLMedicare ID - Type Unspecified