Provider Demographics
NPI:1639139439
Name:PIESCHKE, GLENN D (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:PIESCHKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 S PATRICK DRIVE
Mailing Address - Street 2:45TH MEDICAL GROUP ATTN CREDENTIALS OFFICE
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925
Mailing Address - Country:US
Mailing Address - Phone:321-494-8159
Mailing Address - Fax:321-494-1378
Practice Address - Street 1:3101 SW COLLEGE RD
Practice Address - Street 2:LANGE EYECARE
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474
Practice Address - Country:US
Practice Address - Phone:352-237-3768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U17890Medicare UPIN