Provider Demographics
NPI:1659698660
Name:BEMUS, GLENN T
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:T
Last Name:BEMUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2406
Mailing Address - Country:US
Mailing Address - Phone:203-372-2010
Mailing Address - Fax:203-372-2011
Practice Address - Street 1:2480 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-2406
Practice Address - Country:US
Practice Address - Phone:203-372-2010
Practice Address - Fax:203-372-2011
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001115156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician