Healthcare Provider Details

I. General information

NPI: 1912967894
Provider Name (Legal Business Name): GLENN YUKIO MIYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W BASELINE RD
CLAREMONT CA
91711-1607
US

IV. Provider business mailing address

840 TOWNE CENTER DR CHAPARRAL MEDICAL GROUP
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-621-3916
  • Fax: 909-625-0903
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG70876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: