Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 007561 | AZ |
NPI | 1285636126 |
---|---|
Provider Name | John Glazer |
First Address | Bisbee, AZ 85603-1327 |
Second Address | Hereford, AZ 85615 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2005 |
Last Update Date | 24/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
400232 | (05) | AZ |
G76791 | (02) | FL |
Z216210 | MEDICARE (01) | AZ |