Healthcare Provider Details

I. General information

NPI: 1366494023
Provider Name (Legal Business Name): RENEE F GLASS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WASHINGTON ST STE 510
SAN DIEGO CA
92103-2231
US

IV. Provider business mailing address

PO BOX 34307
SAN DIEGO CA
92163-4307
US

V. Phone/Fax

Practice location:
  • Phone: 619-819-6577
  • Fax:
Mailing address:
  • Phone: 866-752-2080
  • Fax: 866-752-2240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG48232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: