1295731826 NPI number — DR. GLEN ROBERT JUSTICE M.D.

Table of content: DR. GLEN ROBERT JUSTICE M.D. (NPI 1295731826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295731826 NPI number — DR. GLEN ROBERT JUSTICE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTICE
Provider First Name:
GLEN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295731826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9940 TALBERT AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
FOUNTAIN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92708-5153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-0200
Provider Business Mailing Address Fax Number:
714-435-1420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9940 TALBERT AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
FOUNTAIN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92708-5153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-845-0200
Provider Business Practice Location Address Fax Number:
714-435-1420
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G23862 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X , with the licence number: G23862 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 953431486 0073 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G238620 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ21205Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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