Provider Demographics
NPI:1619939550
Name:HOFSTROM, GLEN THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:THEODORE
Last Name:HOFSTROM
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-6727
Practice Address - Country:US
Practice Address - Phone:570-326-2447
Practice Address - Fax:570-326-1247
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019823E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA544226OtherAETNA
PA001793OtherFIRST PRIORITY HEALTH
PAB34545OtherHEALTHAMERICA
PA0010813260001Medicaid
PA057619OtherHIGHMARK BLUE SHIELD
PA1553395OtherUNITEDHEALTHCARE
PA001793OtherFIRST PRIORITY HEALTH
PA1553395OtherUNITEDHEALTHCARE
PA057619Medicare PIN