Provider Demographics
NPI:1477282416
Name:GLIDEWELL, KEVIN S
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:GLIDEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 E 3RD DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-1401
Mailing Address - Country:US
Mailing Address - Phone:480-203-6855
Mailing Address - Fax:480-900-8853
Practice Address - Street 1:2041 E 3RD DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-1401
Practice Address - Country:US
Practice Address - Phone:480-203-6855
Practice Address - Fax:480-900-8853
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D2197602202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology