Provider Demographics
NPI:1053892943
Name:COFFIN, GLENN ALLEN (OD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ALLEN
Last Name:COFFIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 FIRST COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2217
Mailing Address - Country:US
Mailing Address - Phone:757-425-5550
Mailing Address - Fax:
Practice Address - Street 1:1201 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2217
Practice Address - Country:US
Practice Address - Phone:757-425-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002731152W00000X
NYT008877152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist