Provider Demographics
NPI:1760464168
Name:GLENN, JEFFREY C (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:GLENN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 W NEWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2245
Mailing Address - Country:US
Mailing Address - Phone:352-336-6000
Mailing Address - Fax:352-332-0799
Practice Address - Street 1:146 SW ORTHOPEDIC CT
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-0672
Practice Address - Country:US
Practice Address - Phone:386-755-9215
Practice Address - Fax:386-755-6469
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8018207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114984483Medicaid
OH2102352Medicaid
P00371746Medicare PIN
H01795Medicare UPIN
MI114984483Medicaid
OHGL4069356Medicare PIN
OH2102352Medicaid