Provider Demographics
NPI:1821658394
Name:GLIDEWELL, GEOFFREY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:PAUL
Last Name:GLIDEWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 MANNING DRIVE
Practice Address - Street 2:CAMPUS BOX #7025
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-2922
Practice Address - Country:US
Practice Address - Phone:919-966-8162
Practice Address - Fax:919-966-2922
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND185082084P0800X
390200000X
NCRTL23-0072390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry