Provider Demographics
NPI:1275528366
Name:DRAGON, GLENN M (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:DRAGON
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 1:509 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1617
Mailing Address - Country:US
Mailing Address - Phone:856-845-0100
Mailing Address - Fax:856-848-7023
Practice Address - Street 1:509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1617
Practice Address - Country:US
Practice Address - Phone:856-848-4464
Practice Address - Fax:856-848-7023
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05686000207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA56860OtherMEDI CAL LICENSE
NJD05550100OtherCDS
NJ6566405Medicaid
NJ6566405Medicaid
BD4439736OtherDEA
783322Medicare ID - Type Unspecified