Provider Demographics
NPI:1992765994
Name:HOCKETT, GLENN ERIC (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ERIC
Last Name:HOCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 HICKMAN RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-1121
Mailing Address - Country:US
Mailing Address - Phone:515-274-3551
Mailing Address - Fax:515-274-3512
Practice Address - Street 1:5700 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-1121
Practice Address - Country:US
Practice Address - Phone:515-274-3551
Practice Address - Fax:515-274-3512
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA183061Medicaid
IA1992765994Medicaid
IA719260249Medicare PIN
IA52955Medicare PIN
IA1992765994Medicaid
IA183061Medicaid