Provider Demographics
NPI:1730391590
Name:GLEN A WASKIN DO PA
Entity type:Organization
Organization Name:GLEN A WASKIN DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WASKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-782-0010
Mailing Address - Street 1:1800 NORTH FEDERAL HIGHWAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062
Mailing Address - Country:US
Mailing Address - Phone:954-782-0010
Mailing Address - Fax:954-781-2139
Practice Address - Street 1:1800 NORTH FEDERAL HIGHWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062
Practice Address - Country:US
Practice Address - Phone:954-782-0010
Practice Address - Fax:954-781-2139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K4793Medicare ID - Type UnspecifiedMEDICARE GRP NUMBER