Provider Demographics
NPI:1023067360
Name:ZEIDMAN, GLENN (DO)
Entity type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:ZEIDMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-5952
Mailing Address - Country:US
Mailing Address - Phone:601-250-0139
Mailing Address - Fax:601-250-0139
Practice Address - Street 1:1126 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-5952
Practice Address - Country:US
Practice Address - Phone:601-250-0139
Practice Address - Fax:601-250-0139
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00433021Medicaid
MS080004035Medicare PIN
MS00433021Medicaid