Healthcare Provider Details

I. General information

NPI: 1306034566
Provider Name (Legal Business Name): MARIA LEE GLASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA LEE DE LA CRUZ

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 FEDERAL DR NW SUITE 200
CORYDON IN
47112-3070
US

IV. Provider business mailing address

313 FEDERAL DR NW SUITE 200
CORYDON IN
47112-3070
US

V. Phone/Fax

Practice location:
  • Phone: 812-738-4155
  • Fax: 812-738-6104
Mailing address:
  • Phone: 812-738-4155
  • Fax: 812-738-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01066600A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: