Provider Demographics
NPI:1497714422
Name:WING, GLENN L (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:WING
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 60559
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-6559
Mailing Address - Country:US
Mailing Address - Phone:239-939-4323
Mailing Address - Fax:239-939-3983
Practice Address - Street 1:6901 INTERNATIONAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7125
Practice Address - Country:US
Practice Address - Phone:239-939-4323
Practice Address - Fax:239-939-3983
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0039419207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCA7010OtherRAILROAD MEDICARE GROUP
FL043884700Medicaid
FL374440000Medicaid
FL180022163OtherRAILROAD MEDICARE
FL180022163OtherRAILROAD MEDICARE
FL374440000Medicaid
FL33090Medicare PIN
FLB97002Medicare UPIN