Provider Demographics
NPI:1740328053
Name:WHEATON, GLENN TODD (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:TODD
Last Name:WHEATON
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 1:531 ROSELANE ST NW STE 830
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6979
Mailing Address - Country:US
Mailing Address - Phone:770-794-0477
Mailing Address - Fax:770-794-3108
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044142207LP3000X, 208VP0000X, 208VP0014X, 207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000755664AMedicaid
GA000755664AMedicaid