Provider Demographics
NPI:1093133027
Name:LASAM, GLENMORE (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENMORE
Middle Name:
Last Name:LASAM
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 1:415 E HARDING WAY STE D
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6118
Mailing Address - Country:US
Mailing Address - Phone:209-944-5750
Mailing Address - Fax:209-464-2684
Practice Address - Street 1:1148 NORMAN DR STE 3
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5961
Practice Address - Country:US
Practice Address - Phone:209-824-1555
Practice Address - Fax:209-464-2684
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10197800207R00000X
0390200000X
CAA171671207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program