Healthcare Provider Details

I. General information

NPI: 1679947949
Provider Name (Legal Business Name): GLENN MICHELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 BOLIVAR DR
BERKELEY CA
94710-2210
US

IV. Provider business mailing address

91 BOLIVAR DR
BERKELEY CA
94710-2210
US

V. Phone/Fax

Practice location:
  • Phone: 510-647-4252
  • Fax: 510-548-8014
Mailing address:
  • Phone: 510-647-4252
  • Fax: 510-548-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberG85101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: