Provider Demographics
NPI:1730151119
Name:GLASSMAN, BRUCE DAVID (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:DAVID
Last Name:GLASSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-370-0073
Mailing Address - Fax:703-370-2002
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-370-0073
Practice Address - Fax:703-370-2002
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051255207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5900786Medicaid
DCF26348Medicare UPIN
VA5900786Medicaid