Provider Demographics
NPI:1073660353
Name:GLENOAKS PODIATRY GROUP INC
Entity Type:Organization
Organization Name:GLENOAKS PODIATRY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GULBENK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRVANIAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-500-1888
Mailing Address - Street 1:844 WEST GLENOAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2134
Mailing Address - Country:US
Mailing Address - Phone:818-500-1888
Mailing Address - Fax:818-500-0695
Practice Address - Street 1:844 WEST GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2134
Practice Address - Country:US
Practice Address - Phone:818-500-1888
Practice Address - Fax:818-500-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2979213E00000X
CAE2857213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE00160Medicaid
CAGRE00160Medicaid
T11539Medicare UPIN