Provider Demographics
NPI:1497836266
Name:LINSLEY, GLEN A (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:LINSLEY
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 1:109 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854
Mailing Address - Country:US
Mailing Address - Phone:517-676-4499
Mailing Address - Fax:517-676-3221
Practice Address - Street 1:109 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854
Practice Address - Country:US
Practice Address - Phone:517-676-4499
Practice Address - Fax:517-676-3221
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945050168Medicaid
MI0C36542OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIMI3321001Medicare PIN
MI0C36542OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIC30397Medicare UPIN