Provider Demographics
NPI:1790700961
Name:CHRYSTAL, GLENN S (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:S
Last Name:CHRYSTAL
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 1:1236 HUFFMAN MILL RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1236 HUFFMAN MILL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-7725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC326672085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1012JOtherBCBSNC
NC7922488Medicaid
NC920003109OtherRAILROAD MEDICARE
NC7922488Medicaid
NCD92964Medicare UPIN