Provider Demographics
NPI:1346336575
Name:GOLDSTEIN, GLENN L (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:L
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7900 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4128
Mailing Address - Country:US
Mailing Address - Phone:260-435-1900
Mailing Address - Fax:260-435-1800
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-435-1900
Practice Address - Fax:260-435-1800
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01039960208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN230430AMedicare ID - Type Unspecified
INF09183Medicare UPIN