Provider Demographics
NPI:1265618169
Name:JEROME GLAZER OD
Entity type:Organization
Organization Name:JEROME GLAZER OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:I
Authorized Official - Last Name:GLAZER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-529-5429
Mailing Address - Street 1:67 WELLS RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3043
Mailing Address - Country:US
Mailing Address - Phone:860-529-5429
Mailing Address - Fax:860-563-5202
Practice Address - Street 1:67 WELLS RD
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-3043
Practice Address - Country:US
Practice Address - Phone:860-529-5429
Practice Address - Fax:860-563-5202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT722152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT090000722CT01OtherANTHEM BLUE CROSS OF CT
CT0V0193OtherHEALTH NET
CT13122OtherSPECTERA
CTP386567OtherOXFORD
CT004023875Medicaid
CTC3E541OtherEMPIRE BLUE CROSS
CT138028OtherWELLCARE OF CT
CT00402387501OtherBLUE CARE FAMILY PLAN
CT912918OtherBLOCK MEDICAIDE
CT112728OtherEYEMED
CT1497774301OtherNPI
CT17098OtherAVESIS
CT773845OtherCONNECTICARE
CT=========OtherAETNA
CTC3E541OtherEMPIRE BLUE CROSS
CT17098OtherAVESIS