Healthcare Provider Details

I. General information

NPI: 1902822059
Provider Name (Legal Business Name): GLENN PAUL MATNEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12402 INDUSTRIAL BLVD STE B1
VICTORVILLE CA
92395-5889
US

IV. Provider business mailing address

12402 INDUSTRIAL BLVD STE B1
VICTORVILLE CA
92395-5889
US

V. Phone/Fax

Practice location:
  • Phone: 760-245-9363
  • Fax:
Mailing address:
  • Phone: 760-245-9363
  • Fax: 760-245-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG069064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: