Healthcare Provider Details

I. General information

NPI: 1992762355
Provider Name (Legal Business Name): GLENDORA PEDIATRICS MED GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S GRAND AVE STE 202
GLENDORA CA
91741
US

IV. Provider business mailing address

210 S GRAND AVE STE 202
GLENDORA CA
91741
US

V. Phone/Fax

Practice location:
  • Phone: 626-335-0211
  • Fax: 626-335-7986
Mailing address:
  • Phone: 626-335-0211
  • Fax: 626-335-7986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA65278
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA65758
License Number StateCA

VIII. Authorized Official

Name: JANET P FERMIN
Title or Position: DOCTOR
Credential: MD
Phone: 626-335-0211