Provider Demographics
NPI:1962484592
Name:PATRIZIO, GLEN R (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:R
Last Name:PATRIZIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4355 W RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-7734
Mailing Address - Country:US
Mailing Address - Phone:541-705-7505
Mailing Address - Fax:971-244-9050
Practice Address - Street 1:1625 WOODS CT STE 102
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2919
Practice Address - Country:US
Practice Address - Phone:541-436-2960
Practice Address - Fax:541-436-2961
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24391207QH0002X, 207Q00000X
WAMD60191672207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227266Medicaid
H88455Medicare UPIN
OR227266Medicaid
OR227266Medicaid