1497774301 NPI number — JEROME I GLAZER O.D.

Table of content: JEROME I GLAZER O.D. (NPI 1497774301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497774301 NPI number — JEROME I GLAZER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLAZER
Provider First Name:
JEROME
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497774301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 WELLS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06109-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-529-5429
Provider Business Mailing Address Fax Number:
860-563-5202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 WELLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WETHERSFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06109-3043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-529-5429
Provider Business Practice Location Address Fax Number:
860-563-5202
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  722 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 138028 . This is a "WELLCARE OF CT MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 912918 . This is a "BLOCK/MEDICAIDE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P386567 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 00402387501 . This is a "BLUECAREFAMILY MEDICAIDE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 13122 . This is a "SPECTERA ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 112728 . This is a "EYE MED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OV0193 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 773845 . This is a "CONNECTICARE ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 090000722CT01 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: C3E541 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004023875 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060873845 . This is a "CT TAX ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 17098 . This is a "AVESIS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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