Provider Demographics
NPI:1659327559
Name:GLASS, JUSTIN TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:TODD
Last Name:GLASS
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 1:10777 SUNSET OFFICE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1019
Mailing Address - Country:US
Mailing Address - Phone:314-842-4802
Mailing Address - Fax:314-849-8721
Practice Address - Street 1:10777 SUNSET OFFICE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1019
Practice Address - Country:US
Practice Address - Phone:314-842-4802
Practice Address - Fax:314-849-8721
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001005040207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO162938OtherBLUE CROSS BLUE SHIELD
MO07001294OtherUNITED HEALTHCARE
MO242135OtherGROUP HEALTH PLAN
MO205838501Medicaid
MO484339OtherHEALTHLINK
MO07001294OtherUNITED HEALTHCARE
MO242135OtherGROUP HEALTH PLAN