Provider Demographics
NPI:1366448110
Name:ROTHHAAS, GLENN P (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:P
Last Name:ROTHHAAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3900 SUNFOREST CT
Mailing Address - Street 2:STE 119
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4440
Mailing Address - Country:US
Mailing Address - Phone:419-472-3791
Mailing Address - Fax:419-472-6219
Practice Address - Street 1:3900 SUNFOREST CT
Practice Address - Street 2:STE 119
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4440
Practice Address - Country:US
Practice Address - Phone:419-472-3791
Practice Address - Fax:419-472-6219
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34-00-4787-R207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0329424Medicaid
OHG39042Medicare UPIN
OHRO0812637Medicare PIN