Healthcare Provider Details

I. General information

NPI: 1639139439
Provider Name (Legal Business Name): GLENN D PIESCHKE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 09/24/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3247 US HWY 441127
FRUITLAND PARK FL
34731
US

IV. Provider business mailing address

2015 LEGENDS WAY
CLERMONT FL
34711
US

V. Phone/Fax

Practice location:
  • Phone: 352-360-2301
  • Fax: 352-315-7631
Mailing address:
  • Phone: 352-360-2301
  • Fax: 352-315-7632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: