=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154387389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLEN ERIK TONNESSEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2006
-----------------------------------------------------
Last Update Date | 03/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 WESCOTT DRIVE SUITE G 3
-----------------------------------------------------
City | FLEMINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-788-1710
-----------------------------------------------------
Fax | 908-788-1716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 WESCOTT DRIVE SUITE G 3
-----------------------------------------------------
City | FLEMINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-788-1710
-----------------------------------------------------
Fax | 908-788-1716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 202K00000X
-----------------------------------------------------
Taxonomy Name | Phlebology Physician
-----------------------------------------------------
License Number | 25MA05512900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | MA055129
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------