Provider Demographics
NPI:1245296243
Name:GLAZIER, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GLAZIER
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 1:477 LAKEHURST RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-6342
Mailing Address - Country:US
Mailing Address - Phone:732-349-4422
Mailing Address - Fax:
Practice Address - Street 1:477 LAKEHURST RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6342
Practice Address - Country:US
Practice Address - Phone:732-349-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07182400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8993106Medicaid
NJ062993Medicare ID - Type Unspecified
NJ8993106Medicaid