Provider Demographics
NPI:1265487862
Name:KASOW, GLENN (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:KASOW
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2179 NORTHLAKE PARKWAY
Mailing Address - Street 2:STE 109
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-491-9400
Mailing Address - Fax:770-491-9402
Practice Address - Street 1:2179 NORTHLAKE PARKWAY
Practice Address - Street 2:STE 109
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-491-9400
Practice Address - Fax:770-491-9402
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA14149208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40322Medicare UPIN