Provider Demographics
NPI:1619198546
Name:BUCKSPAN, GLENN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:SCOTT
Last Name:BUCKSPAN
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 1:2204 CRESTMOOR ROAD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215
Mailing Address - Country:US
Mailing Address - Phone:615-385-3309
Mailing Address - Fax:615-385-9921
Practice Address - Street 1:2204 CRESTMOOR ROAD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215
Practice Address - Country:US
Practice Address - Phone:615-385-3309
Practice Address - Fax:615-385-9921
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD10053174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3191853Medicaid
TN3191853Medicaid
TN3384123Medicare ID - Type Unspecified