Provider Demographics
NPI:1306046420
Name:GARY S GLENN OD PC
Entity type:Organization
Organization Name:GARY S GLENN OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-848-4444
Mailing Address - Street 1:9302 N MERIDIAN ST
Mailing Address - Street 2:STE 150
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1873
Mailing Address - Country:US
Mailing Address - Phone:317-848-4444
Mailing Address - Fax:
Practice Address - Street 1:9302 N MERIDIAN ST
Practice Address - Street 2:STE 150
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1873
Practice Address - Country:US
Practice Address - Phone:317-848-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN266260Medicare PIN