Provider Demographics
NPI:1063693000
Name:GROSSMAN, GLENN MARK (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MARK
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11600 INDIAN HILLS RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1225
Mailing Address - Country:US
Mailing Address - Phone:818-838-4500
Mailing Address - Fax:
Practice Address - Street 1:11600 INDIAN HILLS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1225
Practice Address - Country:US
Practice Address - Phone:818-838-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2012-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG74125207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F36206Medicare UPIN