Provider Demographics
NPI:1609892777
Name:KNOX, GLENN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:KNOX
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 1:12276 SAN JOSE BLVD
Mailing Address - Street 2:516
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8628
Mailing Address - Country:US
Mailing Address - Phone:904-272-9777
Mailing Address - Fax:904-272-1313
Practice Address - Street 1:12276 SAN JOSE BLVD
Practice Address - Street 2:516
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8628
Practice Address - Country:US
Practice Address - Phone:904-272-9777
Practice Address - Fax:904-272-1313
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75455207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00276621OtherRAILROAD MEDICARE
FLK1480Medicare ID - Type Unspecified
FL12622YMedicare ID - Type UnspecifiedMEDICARE PROVIDER
FLP00276621OtherRAILROAD MEDICARE