Provider Demographics
NPI:1184686495
Name:GLOCKNER, SUSAN MARISCAL (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARISCAL
Last Name:GLOCKNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 N EL CAMINO REAL
Mailing Address - Street 2:A306
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1328
Mailing Address - Country:US
Mailing Address - Phone:760-942-0118
Mailing Address - Fax:760-557-0128
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:A306
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:760-942-0118
Practice Address - Fax:760-557-0128
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG69730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE92398Medicare UPIN