Provider Demographics
NPI:1568039535
Name:REID, GLEN ANTOINE JR
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ANTOINE
Last Name:REID
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19853 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2066
Mailing Address - Country:US
Mailing Address - Phone:347-526-6915
Mailing Address - Fax:
Practice Address - Street 1:19853 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2066
Practice Address - Country:US
Practice Address - Phone:313-406-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW231852855OtherAETNA