Healthcare Provider Details

I. General information

NPI: 1780731976
Provider Name (Legal Business Name): MARCIA JANEL GLENN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 N PRAIRIE AVE
INGLEWOOD CA
90301-1413
US

IV. Provider business mailing address

447 N PRAIRIE AVE
INGLEWOOD CA
90301-1413
US

V. Phone/Fax

Practice location:
  • Phone: 310-821-7658
  • Fax: 424-309-9057
Mailing address:
  • Phone: 310-821-7658
  • Fax: 424-309-9057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberG63373
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG63373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: