Healthcare Provider Details

I. General information

NPI: 1396984423
Provider Name (Legal Business Name): MARCIA J GLENN MD & ASSOCIATES DERMATOLOGY & LASER MED CTR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2009
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4644 LINCOLN BLVD STE 500
MARINA DEL REY CA
90292-6391
US

IV. Provider business mailing address

4644 LINCOLN BLVD STE 500
MARINA DEL REY CA
90292-6391
US

V. Phone/Fax

Practice location:
  • Phone: 310-821-7658
  • Fax: 310-301-1783
Mailing address:
  • Phone: 310-821-7658
  • Fax: 310-821-1708

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: MARCIA J GLENN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-821-7658