Provider Demographics
NPI:1124137898
Name:GLASSER, JACK DAVID (MD)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:DAVID
Last Name:GLASSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MORNING GLORY DR
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-2111
Mailing Address - Country:US
Mailing Address - Phone:203-374-4689
Mailing Address - Fax:203-374-3115
Practice Address - Street 1:55 MORNING GLORY DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:CT
Practice Address - Zip Code:06612-2111
Practice Address - Country:US
Practice Address - Phone:203-374-4689
Practice Address - Fax:203-374-3115
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17206207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001172063Medicaid
CT110000757Medicare ID - Type Unspecified
C64861Medicare UPIN