Provider Demographics
NPI:1588659957
Name:DIACON, GLEN EDWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:DIACON
Suffix:JR
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 1:1414 ARLINGTON ST
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2643
Mailing Address - Country:US
Mailing Address - Phone:580-332-0112
Mailing Address - Fax:580-332-1005
Practice Address - Street 1:1414 ARLINGTON ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2643
Practice Address - Country:US
Practice Address - Phone:580-332-0112
Practice Address - Fax:580-332-1005
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK16231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100137260AMedicaid
OKE08017Medicare UPIN