Provider Demographics
NPI:1104897289
Name:GLOUSMAN, RONALD ERIC (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:ERIC
Last Name:GLOUSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 570627
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-0627
Mailing Address - Country:US
Mailing Address - Phone:310-659-9116
Mailing Address - Fax:866-807-7466
Practice Address - Street 1:999 N TUSTIN AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3528
Practice Address - Country:US
Practice Address - Phone:310-659-9116
Practice Address - Fax:866-807-7466
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45186207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49931Medicare UPIN
CAEW675ZMedicare PIN