Provider Demographics
NPI:1679544381
Name:PUERTOLLANO, GLENN RIEGO (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:RIEGO
Last Name:PUERTOLLANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2748
Mailing Address - Street 2:RED RIVER HEALTH CARE
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2748
Mailing Address - Country:US
Mailing Address - Phone:606-432-3221
Mailing Address - Fax:606-437-0438
Practice Address - Street 1:321C EAST COLLEGE AVE
Practice Address - Street 2:RED RIVER HEALTH CARE
Practice Address - City:STANTON
Practice Address - State:KY
Practice Address - Zip Code:40380
Practice Address - Country:US
Practice Address - Phone:606-663-9797
Practice Address - Fax:606-663-9470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64094683Medicaid
I16569Medicare UPIN
0536711Medicare ID - Type UnspecifiedFOR SALYERSVILLE MED CENT