Provider Demographics
NPI:1740249143
Name:GMYREK, GLENN A (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:GMYREK
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 1:15-01 BROADWAY, RT 4 WEST
Mailing Address - Street 2:SUITES 1 & 3
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-791-4544
Mailing Address - Fax:201-791-6585
Practice Address - Street 1:15-01 BROADWAY, RT 4 WEST
Practice Address - Street 2:SUITES 1 & 3
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-791-4544
Practice Address - Fax:201-791-6585
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07435800208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H66197Medicare UPIN