1639673536 NPI number — DR. GLEN CHARLES HOOKEY MD

Table of content: DR. GLEN CHARLES HOOKEY MD (NPI 1639673536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639673536 NPI number — DR. GLEN CHARLES HOOKEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOOKEY
Provider First Name:
GLEN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1639673536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 GRESHAM DRIVE
Provider Second Line Business Mailing Address:
RALEIGH BUILDING, SUITE 304
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-388-3397
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 COFFEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-526-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2018

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: 207P00000X , with the licence number:  A174450 , 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)





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