Provider Demographics
NPI:1467415778
Name:GLAZER, JEFFREY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:GLAZER
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:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-772-8189
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1033
Practice Address - Country:US
Practice Address - Phone:812-218-8926
Practice Address - Fax:812-218-8930
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25111207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64251119Medicaid
KYK205680OtherMEDICARE PTAN-AMERICANA
KYK205685OtherMEDICARE PTAN - SOUTHWEST
KYK205681OtherMEDICARE PTAN - PORTLAND
KYK205682OtherMEDICARE PTAN- EAST BROADWAY
KYK205686OtherMEDICARE PTAN- FAIRDALE
KYK205683OtherMEDICARE PTAN - IROQUOIS
KYK205684OtherMEDICARE PTAN - PHOENIX
KYC69501Medicare UPIN