Provider Demographics
NPI:1336143320
Name:GLENN, JAMES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:GLENN
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 1:2338 COUNTY HIGHWAY 280 E
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-5623
Mailing Address - Country:US
Mailing Address - Phone:850-420-6566
Mailing Address - Fax:
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:850-420-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63572207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18895OtherBCBS
FL3525756OtherCIGNA
FL5681078OtherAETNA
FL3525756OtherCIGNA
FL280119100Medicaid
FL5681078OtherAETNA