Provider Demographics
NPI:1427035849
Name:VANATTA, GLEN B (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:B
Last Name:VANATTA
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:PO BOX 76629
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-6500
Mailing Address - Country:US
Mailing Address - Phone:800-527-3872
Mailing Address - Fax:419-222-0384
Practice Address - Street 1:770 W HIGH ST
Practice Address - Street 2:SUITE 290
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3990
Practice Address - Country:US
Practice Address - Phone:800-527-3872
Practice Address - Fax:419-222-0384
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35040106207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528412Medicare PIN