Provider Demographics
NPI:1053421800
Name:DEYO, GLENN ACORD (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ACORD
Last Name:DEYO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 82ND AVENUE CT W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-2325
Mailing Address - Country:US
Mailing Address - Phone:253-312-8336
Mailing Address - Fax:253-475-1185
Practice Address - Street 1:4521 82ND AVENUE CT W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-2325
Practice Address - Country:US
Practice Address - Phone:253-312-8336
Practice Address - Fax:253-475-1185
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7030539Medicaid
WA1054279Medicaid
WADE2889OtherREGENCE BLUE SHIELD
WA0054140OtherL & I
WA0054140OtherL & I
WAG115141300Medicare PIN