Provider Demographics
NPI:1972697357
Name:KANAMORI, GLENN S (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:S
Last Name:KANAMORI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4488
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1717 S ORANGE AVE STE 100
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, ORLANDO
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2946
Practice Address - Country:US
Practice Address - Phone:407-650-7715
Practice Address - Fax:407-650-7124
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-04-29
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Provider Licenses
StateLicense IDTaxonomies
CAG65026207Y00000X
FLME115604207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G650260Medicaid
CABM000ZMedicare PIN