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General NPI Number Information
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NPI Number | 1639255060
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Entity Type | Individual
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Provider Name | GLENN DOUGLAS MADOKORO M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 12/02/2022
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Provider Practice Location Address
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Address Line | 2901 W COAST HWY STE 200
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-4045
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Country | US
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Telephone | 949-548-8800
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Fax | 949-548-0248
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Provider Business Mailing Address
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Address Line | 2323 CLIFF DR
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-5124
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Country | US
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Telephone | 949-548-8800
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Fax | 855-324-3537
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | G30192
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License Number State | CA
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