Provider Demographics
NPI:1962465807
Name:SHOPTAUGH, GLENN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MARK
Last Name:SHOPTAUGH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:82 RAVEN HILLS CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1316
Mailing Address - Country:US
Mailing Address - Phone:719-201-4964
Mailing Address - Fax:719-447-8987
Practice Address - Street 1:82 RAVEN HILLS CT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1316
Practice Address - Country:US
Practice Address - Phone:719-201-4964
Practice Address - Fax:719-447-8987
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CO404372080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine