Healthcare Provider Details

I. General information

NPI: 1467594572
Provider Name (Legal Business Name): GARY RAY GLENN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BLOSSOM HILL RD STE 1139
SAN JOSE CA
95123-1243
US

IV. Provider business mailing address

925 BLOSSOM HILL RD STE 1139
SAN JOSE CA
95123-1243
US

V. Phone/Fax

Practice location:
  • Phone: 408-281-3381
  • Fax:
Mailing address:
  • Phone: 408-281-3381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberCA9248T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: