Provider Demographics
NPI:1437252665
Name:MACDONALD, GLENN JOHN (M D)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:JOHN
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 DAVISON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2237
Mailing Address - Country:US
Mailing Address - Phone:516-764-7319
Mailing Address - Fax:561-764-0804
Practice Address - Street 1:26 DAVISON AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-2237
Practice Address - Country:US
Practice Address - Phone:516-764-7319
Practice Address - Fax:561-764-0804
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY15856OtherLICENSE
NY31D961Medicare PIN