Provider Demographics
NPI:1154387389
Name:TONNESSEN, GLEN ERIK (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ERIK
Last Name:TONNESSEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WESCOTT DRIVE
Mailing Address - Street 2:SUITE G 3
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822
Mailing Address - Country:US
Mailing Address - Phone:908-788-1710
Mailing Address - Fax:908-788-1716
Practice Address - Street 1:1100 WESCOTT DRIVE
Practice Address - Street 2:SUITE G 3
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822
Practice Address - Country:US
Practice Address - Phone:908-788-1710
Practice Address - Fax:908-788-1716
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05512900202K00000X
NJMA055129207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5H53003Medicaid
NJ5H53003Medicaid
731781MGGMedicare ID - Type Unspecified