Healthcare Provider Details

I. General information

NPI: 1053358341
Provider Name (Legal Business Name): GLENN ARMAN KALUSTYAN CORNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 2768
SAN ANSELMO CA
94979-2768
US

IV. Provider business mailing address

PO BOX 2768
SAN ANSELMO CA
94979-2768
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-4332
  • Fax: 415-444-9255
Mailing address:
  • Phone: 415-457-4332
  • Fax: 415-444-9255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG33112
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG33112
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: