Healthcare Provider Details

I. General information

NPI: 1124137898
Provider Name (Legal Business Name): JACK DAVID GLASSER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MORNING GLORY DR
EASTON CT
06612-2111
US

IV. Provider business mailing address

55 MORNING GLORY DR
EASTON CT
06612-2111
US

V. Phone/Fax

Practice location:
  • Phone: 203-374-4689
  • Fax: 203-374-3115
Mailing address:
  • Phone: 203-374-4689
  • Fax: 203-374-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17206
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: