Provider Demographics
NPI:1699701680
Name:GLENN, BRADLEY J (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:GLENN
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 1:784 EL PINTADO RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-1407
Mailing Address - Country:US
Mailing Address - Phone:920-562-6481
Mailing Address - Fax:
Practice Address - Street 1:784 EL PINTADO RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-1407
Practice Address - Country:US
Practice Address - Phone:920-562-6481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI474082085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34588100Medicaid
WI34588100Medicaid
WIF38974Medicare UPIN