Provider Demographics
NPI:1992736508
Name:BANKERT, GLENN M (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:BANKERT
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:550 REDSTONE AVE W
Mailing Address - Street 2:SUITE 470
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6428
Mailing Address - Country:US
Mailing Address - Phone:850-689-2223
Mailing Address - Fax:850-689-2204
Practice Address - Street 1:550 REDSTONE AVE W
Practice Address - Street 2:SUITE 470
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6428
Practice Address - Country:US
Practice Address - Phone:850-689-2223
Practice Address - Fax:850-689-2204
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2011-05-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS0005453207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593541523OtherFED TAX IDENTIFICATION
FL049359700Medicaid
FLE61797Medicare UPIN