Provider Demographics
NPI:1306287750
Name:GATIPON, GLENN BLAISE (MD PHD MBA)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:BLAISE
Last Name:GATIPON
Suffix:
Gender:M
Credentials:MD PHD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:400 TOWER RD NE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9416
Mailing Address - Country:US
Mailing Address - Phone:678-581-5252
Mailing Address - Fax:
Practice Address - Street 1:888 OLD MOUNTAIN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3843
Practice Address - Country:US
Practice Address - Phone:770-426-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23962207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine