Provider Demographics
NPI:1992832166
Name:CHASANOFF, GLENN
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:CHASANOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3929
Mailing Address - Country:US
Mailing Address - Phone:203-787-1331
Mailing Address - Fax:203-787-1595
Practice Address - Street 1:951 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3929
Practice Address - Country:US
Practice Address - Phone:203-787-1331
Practice Address - Fax:203-787-1595
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001408111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU85733Medicare UPIN