Provider Demographics
NPI:1235223181
Name:GLATZ, GREGORY R (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:GLATZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 BLANCHETTE DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1878
Mailing Address - Country:US
Mailing Address - Phone:989-224-6881
Mailing Address - Fax:989-227-3347
Practice Address - Street 1:805 S OAKLAND ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2253
Practice Address - Country:US
Practice Address - Phone:989-224-6881
Practice Address - Fax:989-227-3347
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI5101012635207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1146534444Medicaid
MIMI5101012635OtherLICENCE NUMBER
MIMI5101012635OtherLICENCE NUMBER