Provider Demographics
NPI:1609982826
Name:GHOLSTON, GLENN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:GHOLSTON
Suffix:
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 1:1801 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1548
Mailing Address - Country:US
Mailing Address - Phone:515-282-2319
Mailing Address - Fax:515-282-3234
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1548
Practice Address - Country:US
Practice Address - Phone:515-282-2319
Practice Address - Fax:515-282-3234
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR7951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine