Provider Demographics
NPI:1861572992
Name:SUDBURY, GLENN R (OD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:SUDBURY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4814 N HABANA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6871
Mailing Address - Country:US
Mailing Address - Phone:813-870-3942
Mailing Address - Fax:813-876-5338
Practice Address - Street 1:4814 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6871
Practice Address - Country:US
Practice Address - Phone:813-870-3942
Practice Address - Fax:813-876-5338
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1195152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist