Healthcare Provider Details

I. General information

NPI: 1184610263
Provider Name (Legal Business Name): JEFFREY A. GLEZER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 W PARK ST SUITE 301A
URBANA IL
61801-2367
US

IV. Provider business mailing address

1750 E LAKE SHORE DR SUITE 200
DECATUR IL
62521-3803
US

V. Phone/Fax

Practice location:
  • Phone: 217-531-5466
  • Fax: 217-337-2436
Mailing address:
  • Phone: 217-428-6300
  • Fax: 217-233-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: