Healthcare Provider Details

I. General information

NPI: 1376674341
Provider Name (Legal Business Name): JOHN CHARLES GLOVER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 TUOLUMNE ST
VALLEJO CA
94590-5700
US

IV. Provider business mailing address

1310 CLUB DRIVE
VALLEJO CA
94592
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-2001
  • Fax: 707-784-1494
Mailing address:
  • Phone: 707-638-5205
  • Fax: 707-638-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number20A6532
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A6532
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: