Provider Demographics
NPI:1063441434
Name:JOHNSON, GLENN DWIGHT (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DWIGHT
Last Name:JOHNSON
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:DARTMOUTH-HITCHCOCK MEDICAL CENTER
Mailing Address - Street 2:ONE MEDICAL CENTER DRIVE
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-8124
Mailing Address - Fax:603-650-7898
Practice Address - Street 1:DARTMOUTH-HITCHCOCK MEDICAL CENTER
Practice Address - Street 2:ONE MEDICAL CENTER DRIVE
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-8124
Practice Address - Fax:603-650-7898
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6028207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006900Medicaid
NH00000094Medicaid
NHNH6900Medicare ID - Type Unspecified
NH00000094Medicaid