Provider Demographics
NPI:1982687620
Name:MADRID, GLENN M (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:MADRID
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 10700
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-5517
Mailing Address - Country:US
Mailing Address - Phone:970-254-2642
Mailing Address - Fax:
Practice Address - Street 1:1120 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6129
Practice Address - Country:US
Practice Address - Phone:970-241-6011
Practice Address - Fax:970-241-4650
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0028519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01285196Medicaid
COC223138Medicare PIN
CO01285196Medicaid