Provider Demographics
NPI:1316031099
Name:JERROLD GLASSMAN,.M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JERROLD GLASSMAN,.M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-819-7222
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 650
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-819-7222
Mailing Address - Fax:619-299-5023
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 650
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-819-7222
Practice Address - Fax:619-299-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG34309Medicare ID - Type Unspecified