Healthcare Provider Details

I. General information

NPI: 1093133027
Provider Name (Legal Business Name): GLENMORE LASAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 07/19/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 NORMAN DR STE 3
MANTECA CA
95336-5961
US

IV. Provider business mailing address

415 E HARDING WAY STE D
STOCKTON CA
95204-6118
US

V. Phone/Fax

Practice location:
  • Phone: 209-824-1555
  • Fax: 209-464-2684
Mailing address:
  • Phone: 209-944-5750
  • Fax: 209-464-2684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA10197800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA171671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: