Provider Demographics
NPI:1346272788
Name:GLANTZ, EDIE Y (MD)
Entity Type:Individual
Prefix:
First Name:EDIE
Middle Name:Y
Last Name:GLANTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YUNGYEE
Other - Middle Name:
Other - Last Name:CHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2055 EXCHANGE ST
Mailing Address - Street 2:SUITE230
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3419
Mailing Address - Country:US
Mailing Address - Phone:503-338-3803
Mailing Address - Fax:
Practice Address - Street 1:2055 EXCHANGE ST
Practice Address - Street 2:SUITE230
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3419
Practice Address - Country:US
Practice Address - Phone:503-338-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD207482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150642Medicaid
G51886Medicare UPIN
R104807Medicare ID - Type Unspecified