MEDICARE: JONATHAN GLAZE MD

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	207W00000X	Ophthalmology Physician	30330	MS
2	207W00000X	Ophthalmology Physician	68334	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821551714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN GLAZE MD

Provider Business Mailing Address
First Line	:	105 ASBURY CIR STE B
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-450-8500
Fax Number	:	601-450-8501

Provider Business Practice Location Address
First Line	:	105 ASBURY CIR STE B
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1397
Country	:	US
Telephone Number	:	601-450-8500
Fax Number	:	601-450-8501

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

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	03/12/2026

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