Provider Demographics
NPI:1649200270
Name:MINER, GLENN J (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
Last Name:MINER
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 1:6420 E LOWDEN RD
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-6128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1016 N 32ND ST
Practice Address - Street 2:STE. 2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-5107
Practice Address - Country:US
Practice Address - Phone:602-267-7573
Practice Address - Fax:602-267-7595
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ491152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20189547OtherTPIN
AZEGNU52050OtherMPIN