Provider Demographics
NPI:1578884995
Name:GLASCOCK, BRANDY NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDY
Middle Name:NICOLE
Last Name:GLASCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BRANDY
Other - Middle Name:NICOLE
Other - Last Name:BEARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-634-7423
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:573-634-7423
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010018483207Q00000X
IL036.132523207Q00000X
MO2017007972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400097322Medicare UPIN