Provider Demographics
NPI:1477732170
Name:THAYER, GLENN R (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:THAYER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 US 27 S
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-7916
Mailing Address - Country:US
Mailing Address - Phone:863-465-4904
Mailing Address - Fax:863-465-4650
Practice Address - Street 1:27 US 27 S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7916
Practice Address - Country:US
Practice Address - Phone:863-465-4904
Practice Address - Fax:863-465-4650
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19418OtherBCBS OF FL
FLOP0418OtherEYE MED
FLT96167Medicare UPIN
FL19418YMedicare PIN
FL0598730001Medicare NSC