Provider Demographics
NPI:1558353896
Name:GLASS, GREGORY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LEE
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:125 W CATAWBA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1601
Mailing Address - Country:US
Mailing Address - Phone:704-827-3014
Mailing Address - Fax:704-822-9114
Practice Address - Street 1:125 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1601
Practice Address - Country:US
Practice Address - Phone:704-827-3014
Practice Address - Fax:704-822-9114
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9401198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8935752Medicaid
F83629Medicare UPIN
NC8935752Medicaid