Provider Demographics
NPI:1548202989
Name:JOCKLE, GLENN A (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:JOCKLE
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 1:301 ST. PAUL PLACE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 ST. PAUL PLACE, 7TH FLOOR
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-6882
Practice Address - Fax:410-234-2558
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0026956207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS185 / 0015OtherBLUECHOICE
MD429581100Medicaid
MDS797 / 600433-01OtherBC / BS OF MD
MDKU59ST / 600433-01OtherBC / BS OF MD
MDS797 / 600433-01OtherBC / BS OF MD
MDKU59ST / 600433-01OtherBC / BS OF MD