Provider Demographics
NPI:1497774301
Name:GLAZER, JEROME I (OD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:I
Last Name:GLAZER
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 1:67 WELLS RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3043
Mailing Address - Country:US
Mailing Address - Phone:860-529-5429
Mailing Address - Fax:860-563-5202
Practice Address - Street 1:67 WELLS RD
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-3043
Practice Address - Country:US
Practice Address - Phone:860-529-5429
Practice Address - Fax:860-563-5202
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT138028OtherWELLCARE OF CT MEDICARE
CT912918OtherBLOCK/MEDICAIDE
CTP386567OtherOXFORD
CT00402387501OtherBLUECAREFAMILY MEDICAIDE
CT13122OtherSPECTERA ID
CT112728OtherEYE MED
CTOV0193OtherHEALTH NET
CT773845OtherCONNECTICARE ID
CT090000722CT01OtherANTHEM BLUE CROSS
CTC3E541OtherEMPIRE BLUE CROSS
CT004023875Medicaid
CT060873845OtherCT TAX ID
CT17098OtherAVESIS
CT912918OtherBLOCK/MEDICAIDE
CT410000221Medicare ID - Type Unspecified