Provider Demographics
NPI:1093743924
Name:ABERGEL, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:ABERGEL
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE STE 220
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7640
Practice Address - Country:US
Practice Address - Phone:805-384-8071
Practice Address - Fax:805-983-0803
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67324207RI0200X, 207RP1001X, 207RC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A673240Medicaid
H67235Medicare UPIN
W18546Medicare ID - Type Unspecified