1508816489 NPI number — DR. GLENN C MIDDLETON O.D.

Table of content: DR. GLENN C MIDDLETON O.D. (NPI 1508816489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508816489 NPI number — DR. GLENN C MIDDLETON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIDDLETON
Provider First Name:
GLENN
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
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:
1508816489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8614 WESTWOOD CENTER DR FL 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11088 N US HWY 15 501 UNIT 925
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28315-2378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-693-1226
Provider Business Practice Location Address Fax Number:
910-692-8983
Provider Enumeration Date:
05/11/2006

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:  1395 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 890917R , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: FH700070 . This is a "FIRST CAROLINA CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0917R . This is a "BCBS PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 410040072 . This is a "RAILROAD MC PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 192431 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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