Provider Demographics
NPI:1780886879
Name:ASAEDA, GLENN H (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:H
Last Name:ASAEDA
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 1:375 12TH ST # 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-5001
Mailing Address - Country:US
Mailing Address - Phone:718-369-1179
Mailing Address - Fax:
Practice Address - Street 1:9 METROTECH CTR
Practice Address - Street 2:MEDICAL AFFAIRS
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5431
Practice Address - Country:US
Practice Address - Phone:718-999-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207681207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG83492Medicare UPIN