Provider Demographics
NPI:1912360785
Name:GLISSON, COURTENAY (MD)
Entity Type:Individual
Prefix:
First Name:COURTENAY
Middle Name:
Last Name:GLISSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9665
Mailing Address - Country:US
Mailing Address - Phone:662-268-7805
Mailing Address - Fax:
Practice Address - Street 1:1602 SKIPWITH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-289-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101269796207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program