Provider Demographics
NPI:1750384830
Name:GLAZER, JONATHAN K (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:K
Last Name:GLAZER
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 1:3725 11TH CIR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4804
Mailing Address - Country:US
Mailing Address - Phone:772-562-0163
Mailing Address - Fax:772-562-1505
Practice Address - Street 1:3725 11TH CIR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4804
Practice Address - Country:US
Practice Address - Phone:772-562-0163
Practice Address - Fax:772-562-1505
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI452832085R0202X
FLME904522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3695OtherBLUE CROSS AND BLUE SHIELD OF FLORIDA
FL270165100Medicaid
FL270165100Medicaid
FLU3695YMedicare PIN
FLU3695XMedicare PIN