Provider Demographics
NPI:1356349955
Name:MORADIAN, GLENN P (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:P
Last Name:MORADIAN
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:PO BOX 2537
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58802-2537
Mailing Address - Country:US
Mailing Address - Phone:866-338-6472
Mailing Address - Fax:
Practice Address - Street 1:1301 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3821
Practice Address - Country:US
Practice Address - Phone:701-774-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT110182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149530OtherBS INDIVIDUAL PIN NUMBER
UT74070OtherBC OF IDAHO
UTB4059OtherBC OF IDAHO
UTB5651OtherBC OF IDAHO
IDP00203248OtherRR MEDICARE NO
ID804043200Medicaid
ND15042Medicaid
UT74070OtherBC OF IDAHO
ID1129360Medicare PIN