Provider Demographics
NPI:1760437883
Name:KWIAT, GLENN A (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:KWIAT
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 1:1428 PARILLA CIR
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-7052
Mailing Address - Country:US
Mailing Address - Phone:727-207-7630
Mailing Address - Fax:
Practice Address - Street 1:3301 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-925-1903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100907207Q00000X
OH35.057132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0724890Medicaid
FLP00807421OtherMEDICARE RAILROAD
FLPENDINGMedicaid
FL53648OtherBLUE CROSS/BLUE SHIELD OF FLORIDA
FL000297500Medicaid
OH0724890Medicaid
FLPENDINGMedicaid
FLAN084ZMedicare PIN