Healthcare Provider Details

I. General information

NPI: 1053391979
Provider Name (Legal Business Name): JOHN V GLISSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 JESSE JEWELL PKWY SE
GAINESVILLE GA
30501-3834
US

IV. Provider business mailing address

PO BOX 658
GAINESVILLE GA
30503-0658
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-3611
  • Fax: 770-535-7092
Mailing address:
  • Phone: 770-718-1122
  • Fax: 770-535-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number028406
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: