Provider Demographics
NPI:1487733259
Name:GLENN, BRYAN H (DPM)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:H
Last Name:GLENN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W KINGSHIGHWAY STE A
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5929
Mailing Address - Country:US
Mailing Address - Phone:870-239-6004
Mailing Address - Fax:870-972-8603
Practice Address - Street 1:700 W KINGSHIGHWAY STE A
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-5929
Practice Address - Country:US
Practice Address - Phone:870-239-6004
Practice Address - Fax:870-972-8603
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR175213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132181717Medicaid
ARU67311Medicare UPIN
AR5T619Medicare ID - Type UnspecifiedMEDICARE PROVIDER#
AR132181717Medicaid