Provider Demographics
NPI:1376503003
Name:GLISSON, RICHARD DENNIS (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DENNIS
Last Name:GLISSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-0230
Mailing Address - Country:US
Mailing Address - Phone:860-633-8806
Mailing Address - Fax:860-657-3788
Practice Address - Street 1:124 HEBRON AVE STE 1B
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-633-8806
Practice Address - Fax:860-657-3788
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0388192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT300117748OtherRAILROAD MEDICARE
CT300117753OtherRAILROAD MEDICARE
CT040038819CT09OtherANTHEM BC/BS
CT300117769OtherRAILROAD MEDICARE
CT001388190Medicaid
CT040038819CT05OtherANTHEM BC/BS
CT040038819CT02OtherANTHEM BC/BS
CT040038819CT03OtherANTHEM BC/BS
CT300117740OtherRAILROAD MEDICARE
CT300117761OtherRAILROAD MEDICARE
CT040038819CT08OtherANTHEM BC/BS
CT300117757OtherRAILROAD MEDICARE
CT040038819CT08OtherANTHEM BC/BS
CT300003018Medicare ID - Type Unspecified
CT040038819CT02OtherANTHEM BC/BS
CT300002945Medicare PIN
CT300117761OtherRAILROAD MEDICARE
CTG26507Medicare UPIN
CT300117757OtherRAILROAD MEDICARE
CT040038819CT03OtherANTHEM BC/BS