Provider Demographics
NPI:1629085196
Name:HERRMANN, GLENN ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ERIC
Last Name:HERRMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-0767
Mailing Address - Country:US
Mailing Address - Phone:303-664-9400
Mailing Address - Fax:
Practice Address - Street 1:130 OLD LARAMIE TRL E BLDG 4
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-7014
Practice Address - Country:US
Practice Address - Phone:303-664-9400
Practice Address - Fax:303-666-5362
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44716204E00000X, 208200000X, 2082S0099X, 2082S0105X, 208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15035859Medicaid
CO040644Medicare PIN