Provider Demographics
NPI:1992762355
Name:GLENDORA PEDIATRICS MED GROUP INC
Entity type:Organization
Organization Name:GLENDORA PEDIATRICS MED GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:P
Authorized Official - Last Name:FERMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-335-0211
Mailing Address - Street 1:210 S GRAND AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741
Mailing Address - Country:US
Mailing Address - Phone:626-335-0211
Mailing Address - Fax:626-335-7986
Practice Address - Street 1:210 S GRAND AVE STE 202
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741
Practice Address - Country:US
Practice Address - Phone:626-335-0211
Practice Address - Fax:626-335-7986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65758208000000X
CAA65278208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherFED TAX