MEDICARE: DR. GARY S GLENN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18001443A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000089981	OTHER		ANTHEM

General Provider Information

NPI Number	:	1417938374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY S GLENN OD

Provider Business Mailing Address
First Line	:	9302 N MERIDIAN ST
Second Line	:	SUITE 150
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1873
Country	:	US
Telephone Number	:	317-848-4444
Fax Number	:	317-848-7976

Provider Business Practice Location Address
First Line	:	9302 N MERIDIAN ST
Second Line	:	SUITE 150
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1873
Country	:	US
Telephone Number	:	317-848-4444
Fax Number	:	317-848-7976

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/18/2007

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