Provider Demographics
NPI:1639164536
Name:WOMACK, GLENN RUBEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RUBEN
Last Name:WOMACK
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 1:732 ELIZAVILLE AVE
Mailing Address - Street 2:P.O. BOX 344
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041-1139
Mailing Address - Country:US
Mailing Address - Phone:606-849-2323
Mailing Address - Fax:606-849-2025
Practice Address - Street 1:732 ELIZAVILLE AVE
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041-1139
Practice Address - Country:US
Practice Address - Phone:606-849-2323
Practice Address - Fax:606-849-2025
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64159528Medicaid
KY64159528Medicaid
KYC64474Medicare UPIN