Provider Demographics
NPI:1336263102
Name:PRESCOD, GLENN STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:STEPHEN
Last Name:PRESCOD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:333 SCHOOL ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-725-3600
Mailing Address - Fax:401-728-8760
Practice Address - Street 1:333 SCHOOL ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-725-3600
Practice Address - Fax:401-728-8760
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI8767207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI180040482OtherRAILROAD MEDICARE
RI0000022059OtherBLUE SHIELD OF RHODE ISLAND
RI0800693OtherUNITED HEALTHCARE
RI761405OtherTUFTS HEALTH PLAN
RI9020656Medicaid
RI400075OtherBLUE CHIP
RI29732OtherNEIGHBORHOOD HEALTH PLAN OF RI
RI0800693OtherUNITED HEALTHCARE
RI29732OtherNEIGHBORHOOD HEALTH PLAN OF RI
RIF94922Medicare UPIN
RI180040482OtherRAILROAD MEDICARE