Provider Demographics
NPI:1962410324
Name:GLEN, HARRY G (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:G
Last Name:GLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 SOUTH EAST RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478
Mailing Address - Country:US
Mailing Address - Phone:561-252-0946
Mailing Address - Fax:561-575-6850
Practice Address - Street 1:500 FAUNCE CORNER RD
Practice Address - Street 2:SUITE 110
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1278
Practice Address - Country:US
Practice Address - Phone:508-717-0270
Practice Address - Fax:508-995-3060
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME46138174400000X
MA230681207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU2167AMedicare PIN
FLC35029Medicare UPIN