Provider Demographics
NPI:1902966989
Name:MANN, GLENN W
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:W
Last Name:MANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3423 OLNEY LAYTONSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1787
Mailing Address - Country:US
Mailing Address - Phone:301-774-2434
Mailing Address - Fax:301-774-0312
Practice Address - Street 1:3423 OLNEY LAYTONSVILLE RD
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1787
Practice Address - Country:US
Practice Address - Phone:301-774-2434
Practice Address - Fax:301-774-0312
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA674156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0730680001Medicare ID - Type UnspecifiedRETAIL OPTICAL