Provider Demographics
NPI:1801850672
Name:MORAN, GLENN KEITH (DO,FACOFP)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:KEITH
Last Name:MORAN
Suffix:
Gender:M
Credentials:DO,FACOFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 SW 135TH TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4647
Mailing Address - Country:US
Mailing Address - Phone:954-472-5100
Mailing Address - Fax:954-472-5266
Practice Address - Street 1:201 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1856
Practice Address - Country:US
Practice Address - Phone:954-472-5100
Practice Address - Fax:954-472-5266
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80509OtherBLUE CROSS BLUE SHIELD
FL971681OtherAETNA
FL80509Medicare ID - Type Unspecified
FLE95282Medicare UPIN