Provider Demographics
NPI:1427165760
Name:GOMEZ, GLEN SUMULONG
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:SUMULONG
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N BRAND BLVD
Mailing Address - Street 2:SUITE J&K
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3070
Mailing Address - Country:US
Mailing Address - Phone:818-841-5818
Mailing Address - Fax:818-244-7559
Practice Address - Street 1:1111 N BRAND BLVD
Practice Address - Street 2:SUITE J&K
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3070
Practice Address - Country:US
Practice Address - Phone:818-841-5818
Practice Address - Fax:818-244-7559
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHJ524ZMedicare PIN
CAW17215CMedicare PIN