Provider Demographics
NPI:1396874343
Name:GLASSMITH, JEROME B (DPM)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:B
Last Name:GLASSMITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 31ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3462
Mailing Address - Country:US
Mailing Address - Phone:718-278-8020
Mailing Address - Fax:718-278-8599
Practice Address - Street 1:4105 31ST AVENUE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3462
Practice Address - Country:US
Practice Address - Phone:718-278-8020
Practice Address - Fax:718-278-8599
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2400213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1101493690Medicaid
NYACCESS 931365OtherHEALTHNET
NYP62577571OtherMULTIPLAN
NY002400A39OtherHEALTHFIRST
NY825983OtherPENNSYLVANIA BLUE SHIELD
NYP030002400NY01OtherANTHEM 6450
NYP463339OtherOXFORD
NY177233OtherELDERPLAN
NY24409OtherVITRA
NY36528POtherHIP
NY4809110772OtherRR MCR
NY4C4625OtherPHS
NY1870OtherMAGNAHEALTH
NYGJ2400OtherATLANTIS HEALTH
NYP27721OtherBLUE CROSS BLUE SHIELD
NY0086040OtherGHI
NY1870OtherMAGNAHEALTH
NYACCESS 931365OtherHEALTHNET