Provider Demographics
NPI:1588875215
Name:CHARLES, GLENN MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MICHAEL
Last Name:CHARLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 GLADES RD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1420
Mailing Address - Country:US
Mailing Address - Phone:561-395-5544
Mailing Address - Fax:561-395-5153
Practice Address - Street 1:200 GLADES RD
Practice Address - Street 2:SUITE #2
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-1420
Practice Address - Country:US
Practice Address - Phone:561-395-5544
Practice Address - Fax:561-395-5153
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG23168Medicare UPIN