Healthcare Provider Details

I. General information

NPI: 1316171390
Provider Name (Legal Business Name): NICOLAUS WALTER SPIRO GLOMB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

PO BOX 743749
LOS ANGELES CA
90074-3749
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-8000
  • Fax:
Mailing address:
  • Phone: 415-514-3000
  • Fax: 415-502-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberA142978
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA142978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: