Provider Demographics
NPI:1790747897
Name:LURA, GLENN I (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:I
Last Name:LURA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11103 TRINITY BLVD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4538
Mailing Address - Country:US
Mailing Address - Phone:727-312-3355
Mailing Address - Fax:727-312-3356
Practice Address - Street 1:11103 TRINITY BLVD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4538
Practice Address - Country:US
Practice Address - Phone:727-312-3355
Practice Address - Fax:727-312-3356
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME85071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H64037Medicare UPIN
FL13120Medicare PIN