Provider Demographics
NPI:1164627410
Name:JAMES, GLENN W
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:W
Last Name:JAMES
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GLENN
Other - Middle Name:W
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1250 BUNYAN RD
Mailing Address - Street 2:NA
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3147
Mailing Address - Country:US
Mailing Address - Phone:530-257-6541
Mailing Address - Fax:
Practice Address - Street 1:475-750 RICE CANYON ROAD HIGH DESERT STATE PRISON
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96127-0750
Practice Address - Country:US
Practice Address - Phone:530-251-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine