Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | VA 0103000938 | VA |
Y | 222Z00000X | Podiatrist | VA 0103000938 | VA |
NPI | 1073519682 |
---|---|
Provider Name | Glen R Wilensky |
First Address | Richmond, VA 23227-1817 |
Second Address | Richmond, VA 23227-1817 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2005 |
Last Update Date | 19/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01021914 | (05) | VA |
172333 | ANTHEM (01) | VA |
U45134 | (02) |