Provider Demographics
NPI:1245490424
Name:GLISSMEYER, ERIC WALLACE (MD)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:WALLACE
Last Name:GLISSMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1966 S 700 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4104
Mailing Address - Country:US
Mailing Address - Phone:801-298-0076
Mailing Address - Fax:
Practice Address - Street 1:295 CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1287
Practice Address - Country:US
Practice Address - Phone:801-587-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT282NC2000X
390200000X
UT7891781-12052080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No282NC2000XHospitalsGeneral Acute Care HospitalChildren
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program