Provider Demographics
NPI:1003847054
Name:WEISMAN, GLENDA (MD)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:WEISMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:
Other - Last Name:YDROVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8390 E VIA DE VENTURA
Mailing Address - Street 2:SUITE F 110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3188
Mailing Address - Country:US
Mailing Address - Phone:602-541-9263
Mailing Address - Fax:
Practice Address - Street 1:13232 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6459
Practice Address - Country:US
Practice Address - Phone:602-541-9263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067130207R00000X
AZ36289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ221799Medicaid
FL27468Medicare ID - Type Unspecified
AZ221799Medicaid
AZ115842Medicare PIN