Provider Demographics
NPI:1689760886
Name:GLENN, MARK S (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:GLENN
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:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KS
Mailing Address - Zip Code:67665-0535
Mailing Address - Country:US
Mailing Address - Phone:785-483-2451
Mailing Address - Fax:785-483-4986
Practice Address - Street 1:702 N KANSAS
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665-0535
Practice Address - Country:US
Practice Address - Phone:785-483-2451
Practice Address - Fax:785-483-4986
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11533152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5502690001OtherDMEPOS
KS100219210BMedicaid
KS065116Medicare PIN
KS100219210BMedicaid