Healthcare Provider Details

I. General information

NPI: 1134374002
Provider Name (Legal Business Name): GLEN LEE HORTIN MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 03/27/2024
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441 MBC-MMG
ATLANTA GA
30384-9441
US

V. Phone/Fax

Practice location:
  • Phone: 888-663-3488
  • Fax:
Mailing address:
  • Phone: 813-745-7365
  • Fax: 813-449-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberME103153
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number094989
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: