Provider Demographics
NPI:1174522577
Name:GLASS, JON RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:RYAN
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:S-650
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-934-8100
Mailing Address - Fax:504-934-8102
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:S-650
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-934-8100
Practice Address - Fax:504-934-8102
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-01-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA025041208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1046761Medicaid
LA4J830Medicare PIN
LA4J830CV33Medicare PIN