Provider Demographics
NPI:1710942966
Name:GLASS, NICHOLE R (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:R
Last Name:GLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6201 GREENBELT RD
Mailing Address - Street 2:SUITE L1
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2354
Mailing Address - Country:US
Mailing Address - Phone:301-345-1900
Mailing Address - Fax:
Practice Address - Street 1:6201 GREENBELT RD. SUITE L 1 - 3
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740
Practice Address - Country:US
Practice Address - Phone:301-345-1900
Practice Address - Fax:301-345-1749
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0061134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics