Provider Demographics
NPI:1932150257
Name:GLAZE, GARY M (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:GLAZE
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:PO BOX 34120
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-4120
Mailing Address - Country:US
Mailing Address - Phone:775-747-5050
Mailing Address - Fax:775-329-8596
Practice Address - Street 1:380 SIERRA COLLEGE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5092
Practice Address - Country:US
Practice Address - Phone:916-613-3392
Practice Address - Fax:916-266-9318
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2023-04-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A4983207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX49830Medicaid
CA00AX49830Medicaid