Provider Demographics
NPI:1124138292
Name:AVIDON, GLENN STEVEN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:STEVEN
Last Name:AVIDON
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:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32721-0047
Mailing Address - Country:US
Mailing Address - Phone:407-468-4301
Mailing Address - Fax:407-264-8168
Practice Address - Street 1:PO BOX 47
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32721-0047
Practice Address - Country:US
Practice Address - Phone:407-468-4301
Practice Address - Fax:407-264-8168
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423521207L00000X
FLME 40282207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068418000Medicaid
FL068418000Medicaid
PA438231GVQMedicare PIN
FL47610AMedicare ID - Type Unspecified
PA103055391Medicaid