Provider Demographics
NPI:1437158128
Name:MIZRACH, GLENN BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:BRIAN
Last Name:MIZRACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4000A GLENSIDE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-4102
Mailing Address - Country:US
Mailing Address - Phone:804-262-4763
Mailing Address - Fax:804-264-9683
Practice Address - Street 1:4000A GLENSIDE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-4102
Practice Address - Country:US
Practice Address - Phone:804-262-4763
Practice Address - Fax:804-264-9683
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101036863207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA141007OtherANTHEM BCBS
VA141007OtherANTHEM BCBS