Provider Demographics
NPI:1518021377
Name:FITTERMAN, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:FITTERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OLD COUNTRY ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803
Mailing Address - Country:US
Mailing Address - Phone:516-931-5800
Mailing Address - Fax:516-931-1273
Practice Address - Street 1:700 OLD COUNTRY ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803
Practice Address - Country:US
Practice Address - Phone:516-931-5800
Practice Address - Fax:516-931-1273
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177452208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY43F951Medicare PIN
E48813Medicare UPIN