Provider Demographics
NPI:1073734778
Name:GLEN I KOMATSU M D A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GLEN I KOMATSU M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:I
Authorized Official - Last Name:KOMATSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-375-4585
Mailing Address - Street 1:6069 WOODFERN DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-2263
Mailing Address - Country:US
Mailing Address - Phone:310-545-9713
Mailing Address - Fax:310-546-1648
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:PALLIATIVE CARE
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
Practice Address - Country:US
Practice Address - Phone:310-303-6840
Practice Address - Fax:310-303-5574
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH AND SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19493Medicare UPIN
CAW19493Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER