Provider Demographics
NPI:1689839995
Name:LOSACK, GLENN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MARK
Last Name:LOSACK
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 1:115 EAST 9TH STREET
Mailing Address - Street 2:#16D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-5422
Mailing Address - Country:US
Mailing Address - Phone:917-348-2090
Mailing Address - Fax:
Practice Address - Street 1:115 EAST 9TH STREET
Practice Address - Street 2:#16D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-5422
Practice Address - Country:US
Practice Address - Phone:917-348-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYS1585052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry