Healthcare Provider Details

I. General information

NPI: 1487729034
Provider Name (Legal Business Name): MARK JONATHAN GLASGOLD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 RIVER RD
HIGHLAND PARK NJ
08904-1731
US

IV. Provider business mailing address

45 CLEVELAND LN
PRINCETON NJ
08540-3049
US

V. Phone/Fax

Practice location:
  • Phone: 732-846-6540
  • Fax: 732-846-8231
Mailing address:
  • Phone: 609-924-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number25A053904
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: