Provider Demographics
NPI:1821084732
Name:GLASER, JORDAN B (MD PC)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:B
Last Name:GLASER
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 RICHMOND ROAD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2312
Mailing Address - Country:US
Mailing Address - Phone:718-816-3362
Mailing Address - Fax:718-979-5650
Practice Address - Street 1:1408 RICHMOND ROAD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2312
Practice Address - Country:US
Practice Address - Phone:718-816-3362
Practice Address - Fax:718-979-5650
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143039174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00570916Medicaid
31A981Medicare PIN
NYB80365Medicare UPIN