Provider Demographics
NPI:1992743967
Name:VERBOIS, GLENNAL (MD)
Entity type:Individual
Prefix:
First Name:GLENNAL
Middle Name:
Last Name:VERBOIS
Suffix:
Gender:F
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:PO BOX 10183
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34603-0183
Mailing Address - Country:US
Mailing Address - Phone:850-377-2820
Mailing Address - Fax:
Practice Address - Street 1:12440 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2628
Practice Address - Country:US
Practice Address - Phone:352-952-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107359208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03081893Medicaid
MSG52540Medicare UPIN