Provider Demographics
NPI:1245386051
Name:ALLISON, GLENN ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ROY
Last Name:ALLISON
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:PO BOX 3057
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92781-3057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1506
Practice Address - Country:US
Practice Address - Phone:714-633-9761
Practice Address - Fax:714-633-0802
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25063207Y00000X, 2086S0122X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Not Answered2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Not Answered2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42505Medicare UPIN