Provider Demographics
NPI:1508912304
Name:BIGSBY, GLENN EDGAR III (DO, FACOFP)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:EDGAR
Last Name:BIGSBY
Suffix:III
Gender:M
Credentials:DO, FACOFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WHITE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8938
Mailing Address - Country:US
Mailing Address - Phone:407-282-5563
Mailing Address - Fax:
Practice Address - Street 1:530 WHITE RIVER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8938
Practice Address - Country:US
Practice Address - Phone:407-282-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS-5589207Q00000X
IA01335207Q00000X
MOR5860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E36595Medicare UPIN
80136ZMedicare ID - Type Unspecified