Healthcare Provider Details

I. General information

NPI: 1962410324
Provider Name (Legal Business Name): HARRY G GLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FAUNCE CORNER RD SUITE 110
N DARTMOUTH MA
02747-1278
US

IV. Provider business mailing address

2200 SOUTH EAST RANCH ROAD
JUPITER FL
33478
US

V. Phone/Fax

Practice location:
  • Phone: 508-717-0270
  • Fax: 508-995-3060
Mailing address:
  • Phone: 561-252-0946
  • Fax: 561-575-6850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME46138
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number230681
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: