Provider Demographics
NPI:1285655506
Name:SMALLEY, GLENDON WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:GLENDON
Middle Name:WILLIAM
Last Name:SMALLEY
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 1:18 ERIN OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2866
Mailing Address - Country:US
Mailing Address - Phone:478-272-5933
Mailing Address - Fax:478-272-4350
Practice Address - Street 1:18 ERIN OFFICE PARK
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2866
Practice Address - Country:US
Practice Address - Phone:478-272-5933
Practice Address - Fax:478-272-4350
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28892207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00329678AMedicaid
GA00329678DMedicaid
GA410010041OtherRAILROAD MEDICARE
GA00329678AMedicaid
GA00329678DMedicaid
GA$$$$$$$$$BMedicare PIN
GA0164860001Medicare NSC