Provider Demographics
NPI:1942695739
Name:GLASS, STUART (DO)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:GLASS
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 1:401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-8801
Mailing Address - Country:US
Mailing Address - Phone:910-296-0941
Mailing Address - Fax:
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-8801
Practice Address - Country:US
Practice Address - Phone:910-296-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80140207P00000X
390200000X
NC2021-02238207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program