Provider Demographics
NPI:1306034566
Name:GLASS, MARIA LEE (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LEE
Last Name:GLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:LEE
Other - Last Name:DE LA CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:313 FEDERAL DR NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-3070
Mailing Address - Country:US
Mailing Address - Phone:812-738-4155
Mailing Address - Fax:812-738-6104
Practice Address - Street 1:313 FEDERAL DR NW
Practice Address - Street 2:SUITE 200
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-3070
Practice Address - Country:US
Practice Address - Phone:812-738-4155
Practice Address - Fax:812-738-6104
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066600A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN616162OtherANTHEM
IN616162OtherANTHEM