Provider Demographics
NPI:1790850345
Name:GLANCY, KEVIN LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEE
Last Name:GLANCY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N NEIL ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7808
Mailing Address - Country:US
Mailing Address - Phone:217-356-4619
Mailing Address - Fax:217-356-3052
Practice Address - Street 1:2000 N NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7808
Practice Address - Country:US
Practice Address - Phone:217-356-4619
Practice Address - Fax:217-356-3052
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL468240152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U09068Medicare UPIN