Provider Demographics
NPI:1427167204
Name:WASKIN, GLEN ANDREW (DO)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ANDREW
Last Name:WASKIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2701 NE 14TH STREET CSWY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-3535
Mailing Address - Country:US
Mailing Address - Phone:954-545-1560
Mailing Address - Fax:954-545-1561
Practice Address - Street 1:2701 NE 14TH STREET CSWY
Practice Address - Street 2:SUITE 5
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3535
Practice Address - Country:US
Practice Address - Phone:954-545-1560
Practice Address - Fax:954-545-1561
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS 8048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262021900Medicaid
FL01099XMedicare PIN
FL262021900Medicaid