Provider Demographics
NPI:1417148834
Name:PARRIS, GLENN R (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:PARRIS
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 1:4850 SUGARLOAF PKWY STE 501
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2864
Mailing Address - Country:US
Mailing Address - Phone:770-962-1616
Mailing Address - Fax:770-962-7977
Practice Address - Street 1:4850 SUGARLOAF PKWY STE 501
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2864
Practice Address - Country:US
Practice Address - Phone:770-962-1616
Practice Address - Fax:770-962-7977
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300001475CMedicaid
GA300001475CMedicaid