Provider Demographics
NPI:1972787760
Name:IANNUCCI, GLEN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:JOSEPH
Last Name:IANNUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2835 BRANDYWINE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5510
Mailing Address - Country:US
Mailing Address - Phone:404-256-2593
Mailing Address - Fax:770-488-9408
Practice Address - Street 1:3300 OLD MILTON PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-2425
Practice Address - Country:US
Practice Address - Phone:404-256-2593
Practice Address - Fax:770-488-9408
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002845208000000X
GA0645692080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002845OtherRESTRAINING PERMIT #
GA003100495CMedicaid