Provider Demographics
NPI:1417003229
Name:GLASS, ERIC EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:EDWARD
Last Name:GLASS
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 1:7297 FLOREY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2812
Mailing Address - Country:US
Mailing Address - Phone:301-801-3927
Mailing Address - Fax:
Practice Address - Street 1:760 OTAY LAKES RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6915
Practice Address - Country:US
Practice Address - Phone:619-821-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine