Provider Demographics
NPI:1477743722
Name:GLAZIER, BURT J (DO)
Entity type:Individual
Prefix:DR
First Name:BURT
Middle Name:J
Last Name:GLAZIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 W WOODVALLEY ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-3582
Mailing Address - Country:US
Mailing Address - Phone:208-939-0690
Mailing Address - Fax:
Practice Address - Street 1:1851 W WOODVALLEY ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-3582
Practice Address - Country:US
Practice Address - Phone:208-939-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2009-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0 288208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001032801Medicare UPIN
E25172Medicare UPIN
ME0010325Medicare PIN