Provider Demographics
NPI:1265638969
Name:CHAMULAK, GLENN ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ALLEN
Last Name:CHAMULAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4099 AUTUMN VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9128
Mailing Address - Country:US
Mailing Address - Phone:810-750-6630
Mailing Address - Fax:
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:248-652-5264
Practice Address - Fax:248-652-5065
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301054047207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E19769Medicare UPIN