Provider Demographics
NPI:1336283779
Name:SHAPIRO, GLEN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:DAVID
Last Name:SHAPIRO
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 1:1420 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333
Mailing Address - Country:US
Mailing Address - Phone:877-754-6330
Mailing Address - Fax:877-993-1515
Practice Address - Street 1:513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333
Practice Address - Country:US
Practice Address - Phone:877-754-6330
Practice Address - Fax:877-993-1515
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9172207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID100000294843OtherREGENCE
ID0001364855Medicaid
ID11289122OtherPTAN
IDB6493OtherBCID
IDB6493OtherBLUE CROSS
IDP00247850OtherRAILROAD MEDICARE
IDP00247850OtherRAILROAD MEDICARE
ID11289122OtherPTAN