Provider Demographics
NPI:1730173675
Name:JOHNSON, GLEN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:716 MAIDEN CHOICE LANE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5957
Mailing Address - Country:US
Mailing Address - Phone:410-788-7757
Mailing Address - Fax:470-744-3817
Practice Address - Street 1:716 MAIDEN CHOICE LN
Practice Address - Street 2:SUITE 205
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-5943
Practice Address - Country:US
Practice Address - Phone:410-788-7757
Practice Address - Fax:470-744-3817
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD19558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD74653Medicare UPIN
MDB74653Medicare UPIN
MDB74653Medicare UPIN