Provider Demographics
NPI:1114939394
Name:KOMATSU, GLEN ISAMU (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ISAMU
Last Name:KOMATSU
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 1:6069 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:310-375-4585
Mailing Address - Fax:310-375-1735
Practice Address - Street 1:6069 WOODFERN DR
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-2263
Practice Address - Country:US
Practice Address - Phone:310-375-4585
Practice Address - Fax:310-375-1735
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35086208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine