Provider Demographics
NPI:1346242427
Name:NUDELMAN, GLENN L (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:L
Last Name:NUDELMAN
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 1:2191 CHIP DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7645
Mailing Address - Country:US
Mailing Address - Phone:928-486-4387
Mailing Address - Fax:928-302-3515
Practice Address - Street 1:2191 CHIP DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-7645
Practice Address - Country:US
Practice Address - Phone:928-486-4387
Practice Address - Fax:928-302-3515
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14122174400000X, 207R00000X
AZAN14122207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ110044210OtherRAILROAD MEDICARE
AZ1198420002Medicare NSC
AZ110044210OtherRAILROAD MEDICARE