Provider Demographics
NPI:1144281122
Name:ROBERTSON, GLENN L (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:L
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3500
Mailing Address - Fax:801-475-3414
Practice Address - Street 1:2380 N 400 E STE A
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1756
Practice Address - Country:US
Practice Address - Phone:435-554-3240
Practice Address - Fax:435-554-3241
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14903207Q00000X
WY12808A207Q00000X
VA0101246275207Q00000X
UT372285-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4201995Medicaid
UT3006721Medicaid
UTD2870Medicaid
UT006486023Medicare ID - Type Unspecified
UT006709005Medicare PIN