Provider Demographics
NPI:1508855024
Name:ARZADON, GLENN K (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:K
Last Name:ARZADON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-5340
Mailing Address - Country:US
Mailing Address - Phone:443-523-0601
Mailing Address - Fax:410-973-1453
Practice Address - Street 1:11042 NICHOLAS LANE
Practice Address - Street 2:SUITE B102
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3333
Practice Address - Country:US
Practice Address - Phone:443-523-0601
Practice Address - Fax:410-973-1453
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058755207Q00000X
MDD58755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400320900Medicaid
MDH71058Medicare UPIN
MD400320900Medicaid