Provider Demographics
NPI:1679536627
Name:GOLDFARB, GLENN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ROBERT
Last Name:GOLDFARB
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 1:2345 CHESTERFIELD AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1062
Mailing Address - Country:US
Mailing Address - Phone:304-343-0149
Mailing Address - Fax:304-343-2587
Practice Address - Street 1:2345 CHESTERFIELD AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1064
Practice Address - Country:US
Practice Address - Phone:304-343-0149
Practice Address - Fax:304-343-2587
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0089743000Medicaid
WV0601561Medicare ID - Type UnspecifiedPROVIDER NUMBER
WV0089743000Medicaid