Provider Demographics
NPI:1194765420
Name:GLENN, JOHN A JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:GLENN
Suffix:JR
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 1:840 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6734
Mailing Address - Country:US
Mailing Address - Phone:478-374-1310
Mailing Address - Fax:478-374-0302
Practice Address - Street 1:840 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6734
Practice Address - Country:US
Practice Address - Phone:478-374-1310
Practice Address - Fax:478-374-0302
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000613874JMedicaid
GA08BBXDNMedicare ID - Type Unspecified
GA000613874JMedicaid
GA11-3941Medicare ID - Type UnspecifiedRURAL MEDICARE NUMBER