Provider Demographics
NPI:1720028921
Name:GLENN, DANETTE (MD)
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 HURFFVILLE CROSSKEYS RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2337
Mailing Address - Country:US
Mailing Address - Phone:856-309-7700
Mailing Address - Fax:856-770-9194
Practice Address - Street 1:445 HURFFVILLE CROSSKEYS RD BLDG A
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2337
Practice Address - Country:US
Practice Address - Phone:856-218-2312
Practice Address - Fax:856-770-9194
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041291207R00000X
NJMA05317900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01243059Medicaid
NJ0223191Medicaid
PA669074Medicare PIN