Healthcare Provider Details

I. General information

NPI: 1982749834
Provider Name (Legal Business Name): GLEN E. HOFMANN M.D., PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 CLYO ROAD
CENTERVILLE OH
45459
US

IV. Provider business mailing address

7095 CLYO ROAD
CENTERVILLE OH
45459
US

V. Phone/Fax

Practice location:
  • Phone: 937-458-5084
  • Fax: 937-458-5089
Mailing address:
  • Phone: 937-458-5084
  • Fax: 937-458-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number35-05-0680
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: