Provider Demographics
NPI:1992717458
Name:GOLDMAN, GLENN DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DAVID
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:358 CHAMBERLIN LN
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:354 MOUNTAIN VIEW DR STE 300
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5988
Practice Address - Country:US
Practice Address - Phone:802-864-0192
Practice Address - Fax:802-860-4919
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT0420009351207ND0101X, 207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1395Medicaid
NY01669910Medicaid
G30462Medicare UPIN
NY01669910Medicaid