Provider Demographics
NPI:1073834891
Name:GLEN ABERGEL,MD, INC.
Entity Type:Organization
Organization Name:GLEN ABERGEL,MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/SOLE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABERGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-573-0906
Mailing Address - Street 1:2510 LAS POSAS RD STE G
Mailing Address - Street 2:# 202
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3496
Mailing Address - Country:US
Mailing Address - Phone:805-389-1553
Mailing Address - Fax:805-389-1553
Practice Address - Street 1:1910 OUTLET CENTER DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0677
Practice Address - Country:US
Practice Address - Phone:805-485-2400
Practice Address - Fax:805-485-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067324171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH62735Medicare UPIN