Provider Demographics
NPI:1831156587
Name:GLYNN, GARY (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GLYNN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 FOREST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3359
Mailing Address - Country:US
Mailing Address - Phone:513-246-7000
Mailing Address - Fax:
Practice Address - Street 1:6010 S MASON MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3706
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-204-6355
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002779213E00000X
OH36.002779213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0116350Medicaid
OH480017995OtherRAILROAD MEDICARE
OH480017995OtherRAILROAD MEDICARE