Provider Demographics
NPI:1275574345
Name:GLAZER, ELYSE (DO)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:GLAZER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21765 WESTMONT CT
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4817
Mailing Address - Country:US
Mailing Address - Phone:954-309-6579
Mailing Address - Fax:954-577-8107
Practice Address - Street 1:372 17TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5690
Practice Address - Country:US
Practice Address - Phone:772-299-4623
Practice Address - Fax:772-299-4632
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 7268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB72909Medicare UPIN
FL56736YMedicare PIN