Provider Demographics
NPI:1295742948
Name:WAITE, GLENN R (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:WAITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GLENN
Other - Middle Name:RONALD
Other - Last Name:WAITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:232 S WHISPERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4900
Mailing Address - Country:US
Mailing Address - Phone:208-350-6450
Mailing Address - Fax:208-350-6449
Practice Address - Street 1:232 S WHISPERWOOD WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-4900
Practice Address - Country:US
Practice Address - Phone:208-350-6450
Practice Address - Fax:208-350-6449
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8577207Q00000X, 2081P0004X
CAA38237207Q00000X, 2081P0004X
CO23679207Q00000X, 2081P0004X
IDM-11148208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE92571Medicare UPIN