=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699980995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENN D. MADOKORO, M.D, F.A.C.G., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 08/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 HOSPITAL RD SUITE 210
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-548-8800
-----------------------------------------------------
Fax | 949-548-0248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 351 HOSPITAL ROAD SUITE 210
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-548-8800
-----------------------------------------------------
Fax | 949-548-0248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GLENN DOUGLAS MADOKORO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-548-8800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | G30192
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------