Provider Demographics
NPI:1902108764
Name:MILLER, GLENN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:EDWARD
Last Name:MILLER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 OCEAN AVE APT 720
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2148
Mailing Address - Country:US
Mailing Address - Phone:310-963-6433
Mailing Address - Fax:
Practice Address - Street 1:1431 OCEAN AVENUE
Practice Address - Street 2:#720
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2148
Practice Address - Country:US
Practice Address - Phone:310-963-6433
Practice Address - Fax:310-260-7976
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29077207VX0000X
CAG 29077207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG20977OtherG20977