Provider Demographics
NPI:1669455184
Name:YORK, GLENN PATRICK (DPM)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:PATRICK
Last Name:YORK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6069 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4050
Mailing Address - Country:US
Mailing Address - Phone:402-558-8100
Mailing Address - Fax:402-556-6998
Practice Address - Street 1:6069 MAPLE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-4050
Practice Address - Country:US
Practice Address - Phone:402-558-8100
Practice Address - Fax:402-556-6998
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE215213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470773888 00Medicaid
IA0903948Medicaid
NE266316Medicare PIN
NET-65193Medicare UPIN
NE470773888 00Medicaid