1922421171 NPI number — RONALD GLOUSMAN MD MEDICAL CORPORATION

Table of content: (NPI 1922421171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922421171 NPI number — RONALD GLOUSMAN MD MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RONALD GLOUSMAN MD MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1922421171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 570627
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91357-0627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-659-9116
Provider Business Mailing Address Fax Number:
866-807-7466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 N TUSTIN AVE
Provider Second Line Business Practice Location Address:
STE 114
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-3528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-508-1981
Provider Business Practice Location Address Fax Number:
866-807-7466
Provider Enumeration Date:
01/23/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GLOUSMAN
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-659-9116

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1104897289 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".