Provider Demographics
NPI:1265455166
Name:MILLAR, GLENN E (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:E
Last Name:MILLAR
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 1:912 VESSONA CIR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-8725
Mailing Address - Country:US
Mailing Address - Phone:916-984-0135
Mailing Address - Fax:
Practice Address - Street 1:11583 C AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2703
Practice Address - Country:US
Practice Address - Phone:530-889-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAM1402611OtherDEA NUMBER
CAA38656Medicare UPIN
CA00G124010Medicare PIN