Provider Demographics
NPI:1790836575
Name:GLOW, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:GLOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:E
Other - Last Name:GLOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1701 W RILEY RD
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-3521
Mailing Address - Country:US
Mailing Address - Phone:928-970-0417
Mailing Address - Fax:
Practice Address - Street 1:1701 W RILEY RD
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-3521
Practice Address - Country:US
Practice Address - Phone:928-970-0417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD36915Medicare UPIN