Provider Demographics
NPI:1780636019
Name:BIANCHI, GLEN M (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:M
Last Name:BIANCHI
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:PO BOX 698
Mailing Address - Street 2:300 FAIRVIEW AVENUE
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675
Mailing Address - Country:US
Mailing Address - Phone:201-666-4014
Mailing Address - Fax:201-666-4754
Practice Address - Street 1:300 FAIRVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675
Practice Address - Country:US
Practice Address - Phone:201-666-4014
Practice Address - Fax:201-666-4754
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA 07744000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00228763OtherRR MEDICARE
222103828OtherBCBS
NJ080378BK0Medicare ID - Type Unspecified
222103828OtherBCBS