Provider Demographics
NPI:1447247929
Name:GLAESER, KENNETH DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:GLAESER
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 1:3875 GEIST RD
Mailing Address - Street 2:SUITE E #381
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5925
Practice Address - Country:US
Practice Address - Phone:907-458-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5060207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD80611Medicaid
AKMD80611Medicaid
AK161447Medicare PIN