Provider Demographics
NPI:1841450046
Name:REEVES, GLEN IRVING (MD, MPH)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:IRVING
Last Name:REEVES
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8211 TERMINAL RD
Mailing Address - Street 2:NORTHROP GRUMMAN IT, SUITE 1000
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1435
Mailing Address - Country:US
Mailing Address - Phone:703-767-2361
Mailing Address - Fax:
Practice Address - Street 1:8211 TERMINAL RD
Practice Address - Street 2:NORTHROP GRUMMAN IT, SUITE 1000
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1435
Practice Address - Country:US
Practice Address - Phone:703-767-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236997171W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor