Provider Demographics
NPI:1780671677
Name:GRAVES, GLENN E (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:GRAVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:6020 S PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-3028
Mailing Address - Country:US
Mailing Address - Phone:414-294-4660
Mailing Address - Fax:414-281-0959
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-281-0963
Practice Address - Fax:414-281-0959
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27890-020207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI180020621OtherRR MEDICARE
WI391484998011OtherBLUE CROSS
WI31485900Medicaid
WI391484998COtherHUMANA
WI0800065OtherPRIMECARE
WI391484998OtherTAX ID
WI000347365Medicare ID - Type Unspecified
WI391484998COtherHUMANA
WI391484998OtherTAX ID
WI180020621OtherRR MEDICARE
WIE61424Medicare UPIN
0565030002Medicare NSC