Provider Demographics
NPI:1629150024
Name:GLENN, WILLIAM B (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:GLENN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 RT.72 WEST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-3130
Mailing Address - Country:US
Mailing Address - Phone:609-597-7394
Mailing Address - Fax:609-597-6833
Practice Address - Street 1:1301 RT.72 WEST
Practice Address - Street 2:SUITE 240
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-3130
Practice Address - Country:US
Practice Address - Phone:609-597-7394
Practice Address - Fax:609-597-6833
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB52176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2110601Medicaid
NJ223106655OtherTAX ID
NJ223106655OtherTAX ID
GL558560Medicare PIN