Provider Demographics
NPI:1740298850
Name:RUARK, GLEN W (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:RUARK
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 1:1215 N MCDONALD RD
Mailing Address - Street 2:STE 101
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1048
Mailing Address - Country:US
Mailing Address - Phone:509-924-1950
Mailing Address - Fax:509-921-0017
Practice Address - Street 1:1215 N MCDONALD RD
Practice Address - Street 2:STE 101
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1048
Practice Address - Country:US
Practice Address - Phone:509-924-1950
Practice Address - Fax:509-921-0017
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012661207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1749803Medicaid
WA1749803Medicaid