Provider Demographics
NPI:1972645448
Name:GLEN C. CANGELOSI MD LLC
Entity Type:Organization
Organization Name:GLEN C. CANGELOSI MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK BOOKKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS FAYE
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-282-7212
Mailing Address - Street 1:4201 FRENCHMEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-3839
Mailing Address - Country:US
Mailing Address - Phone:504-282-7212
Mailing Address - Fax:504-282-7657
Practice Address - Street 1:4201 FRENCHMEN ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-3839
Practice Address - Country:US
Practice Address - Phone:504-282-7212
Practice Address - Fax:504-282-7657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016166207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1349259Medicaid
B61994Medicare UPIN
LA5CW37Medicare PIN