Provider Demographics
NPI:1275507592
Name:GLINCOSKY, JEROME NORMAN (PAC)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:NORMAN
Last Name:GLINCOSKY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 4TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3813
Mailing Address - Country:US
Mailing Address - Phone:619-422-8338
Mailing Address - Fax:619-476-7679
Practice Address - Street 1:340 4TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3813
Practice Address - Country:US
Practice Address - Phone:619-422-8338
Practice Address - Fax:619-476-7679
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13203207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q12616Medicare UPIN
WPA13203AMedicare ID - Type Unspecified