Healthcare Provider Details

I. General information

NPI: 1225121189
Provider Name (Legal Business Name): GLEN GORMEZANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 TELEGRAPH AVE
OAKLAND CA
94609-2428
US

IV. Provider business mailing address

PO BOX 398398
SAN FRANCISCO CA
94139-8398
US

V. Phone/Fax

Practice location:
  • Phone: 510-547-2244
  • Fax:
Mailing address:
  • Phone: 888-991-1101
  • Fax: 903-787-5854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG58609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: