Provider Demographics
NPI:1942204326
Name:LOWERY, GLEN DAVID (DO)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:DAVID
Last Name:LOWERY
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 1:2039 INDIAN ROCKS RD S
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-1035
Mailing Address - Country:US
Mailing Address - Phone:727-584-7666
Mailing Address - Fax:727-586-1386
Practice Address - Street 1:2039 INDIAN ROCKS RD S
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-1035
Practice Address - Country:US
Practice Address - Phone:727-584-7666
Practice Address - Fax:727-586-1386
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4038208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067548200Medicaid
FL067548200Medicaid
FL82510Medicare ID - Type Unspecified