Provider Demographics
NPI:1972684546
Name:DASHER, GLEN J (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:J
Last Name:DASHER
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 1:1140 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-871-2273
Mailing Address - Fax:912-871-2274
Practice Address - Street 1:1140 BRAMPTON
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-871-2273
Practice Address - Fax:912-871-2274
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000766114EMedicaid
GAG54473Medicare UPIN