Provider Demographics
NPI:1619381852
Name:GLENN, DAVID WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:465 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-282-4700
Mailing Address - Fax:208-282-4696
Practice Address - Street 1:1300 E MULLAN AVE STE 1300
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6057
Practice Address - Country:US
Practice Address - Phone:208-625-5630
Practice Address - Fax:208-625-5631
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-13390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine