Healthcare Provider Details

I. General information

NPI: 1093708778
Provider Name (Legal Business Name): IOANNIS P GLAVAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 03/05/2022
Certification Date: 03/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NEWBURY ST
BOSTON MA
02116-2935
US

IV. Provider business mailing address

115 NEWBURY ST FL 5
BOSTON MA
02116-2935
US

V. Phone/Fax

Practice location:
  • Phone: 617-725-1921
  • Fax: 866-365-1847
Mailing address:
  • Phone: 617-725-1921
  • Fax: 866-365-1847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number207834
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: