Provider Demographics
NPI:1457351736
Name:PIERRE, GLENN N (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:N
Last Name:PIERRE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 LAKE PLAZA DR
Mailing Address - Street 2:STE 230
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3595
Mailing Address - Country:US
Mailing Address - Phone:719-630-8200
Mailing Address - Fax:719-578-5703
Practice Address - Street 1:1130 LAKE PLAZA DRIVE
Practice Address - Street 2:SUITE #230
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-219-3819
Practice Address - Fax:719-219-0411
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT 966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08966996Medicaid
CO08966996Medicaid
CO08966996Medicaid
COMP0243117OtherDEA