Provider Demographics
NPI:1851366959
Name:RAUCHWARG, GLENN T (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:T
Last Name:RAUCHWARG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:5424 DISCOVERY PARK BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188
Practice Address - Country:US
Practice Address - Phone:757-345-2071
Practice Address - Fax:757-903-4877
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102050179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010114349Medicaid
G06959Medicare UPIN
VA010114349Medicaid