Provider Demographics
NPI:1285611582
Name:ZELLMAN, GLENN L (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:ZELLMAN
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 1:2224 W NORTHERN AVE STE D300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5099
Mailing Address - Country:US
Mailing Address - Phone:602-277-1449
Mailing Address - Fax:602-277-9984
Practice Address - Street 1:2224 W NORTHERN AVE STE D300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021
Practice Address - Country:US
Practice Address - Phone:602-277-1449
Practice Address - Fax:602-277-9984
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072954207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG63661Medicare UPIN