MEDICARE: GLEN LORIA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	153712	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730293671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN LORIA MD

Provider Business Mailing Address
First Line	:	119-05 ROCKAWAY BLVD
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-2421
Country	:	US
Telephone Number	:	718-843-3003
Fax Number	:	718-843-3504

Provider Business Practice Location Address
First Line	:	119-05 ROCKAWAY BLVD
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-2421
Country	:	US
Telephone Number	:	718-843-3003
Fax Number	:	718-843-3504

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	07/13/2012

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Directions to “ GLEN LORIA MD” Practice Location

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