Provider Demographics
NPI:1972600310
Name:RICHMOND, GLENN H (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:H
Last Name:RICHMOND
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 1:613 21ST ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3318
Mailing Address - Country:US
Mailing Address - Phone:714-375-2077
Mailing Address - Fax:714-375-2082
Practice Address - Street 1:613 21ST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-3318
Practice Address - Country:US
Practice Address - Phone:714-375-2077
Practice Address - Fax:714-375-2082
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA464982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A464981Medicaid
CAA46498AMedicare ID - Type Unspecified
CAE47957Medicare UPIN