Provider Demographics
NPI:1457477242
Name:GLASCOCK, POONEH HENDI (MD)
Entity Type:Individual
Prefix:
First Name:POONEH
Middle Name:HENDI
Last Name:GLASCOCK
Suffix:
Gender:F
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:PO BOX 5610
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-5610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 10TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1251
Practice Address - Country:US
Practice Address - Phone:319-398-6297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36195207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1457477242OtherBLUE SHIELD
IA1457477242Medicaid
IAIB1436004Medicare PIN