Provider Demographics
NPI:1164484507
Name:GLENDRANGE, RAY ROGERS (MD)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:ROGERS
Last Name:GLENDRANGE
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 1:4605 BROCKTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0106
Mailing Address - Country:US
Mailing Address - Phone:951-686-4911
Mailing Address - Fax:
Practice Address - Street 1:4605 BROCKTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0106
Practice Address - Country:US
Practice Address - Phone:951-686-4911
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61038207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G610380Medicaid
F58407Medicare UPIN