Basic Information
| Provider Information | |||||||||
| NPI: | 1508816489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIDDLETON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 WESTWOOD CENTER DR FL 9 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221822442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 11088 N US HWY 15 501 UNIT 925 | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283152378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106931226 | ||||||||
| FaxNumber: | 9106928983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1395 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 890917R | 05 | NC | MEDICAID | FH700070 | 01 | NC | FIRST CAROLINA CARE | OTHER | 0917R | 01 | NC | BCBS PROVIDER # | OTHER | 410040072 | 01 | NC | RAILROAD MC PROVIDER # | OTHER | 192431 | 01 | NC | MEDCOST | OTHER |