Healthcare Provider Details

I. General information

NPI: 1093750317
Provider Name (Legal Business Name): GLENN HOWARD HERMANN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3416 VIRGINIA AVE SUITE #3
COLLINSVILLE VA
24078-2240
US

IV. Provider business mailing address

3416 VIRGINIA AVE SUITE #3
COLLINSVILLE VA
24078-2240
US

V. Phone/Fax

Practice location:
  • Phone: 276-747-4488
  • Fax: 276-647-7569
Mailing address:
  • Phone: 276-747-4488
  • Fax: 276-647-7569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000497
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618000497
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: