Provider Demographics
NPI:1386755536
Name:MURACA, GLENN J (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
Last Name:MURACA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2042
Mailing Address - Country:US
Mailing Address - Phone:718-805-0037
Mailing Address - Fax:718-849-3737
Practice Address - Street 1:8616 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2042
Practice Address - Country:US
Practice Address - Phone:718-805-0037
Practice Address - Fax:718-849-3737
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01522072Medicaid
NY01522072Medicaid
NYG400001924Medicare PIN