Provider Demographics
NPI:1508816489
Name:MIDDLETON, GLENN C (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:C
Last Name:MIDDLETON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:11088 N US HWY 15 501 UNIT 925
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-2378
Practice Address - Country:US
Practice Address - Phone:910-693-1226
Practice Address - Fax:910-692-8983
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1395152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890917RMedicaid
NCFH700070OtherFIRST CAROLINA CARE
NC0917ROtherBCBS PROVIDER #
NC410040072OtherRAILROAD MC PROVIDER #
NC192431OtherMEDCOST
NC2470629DMedicare PIN
NCFH700070OtherFIRST CAROLINA CARE