Provider Demographics
NPI:1437359940
Name:FLETCHER, GLORILYN TAMANO (OD)
Entity Type:Individual
Prefix:DR
First Name:GLORILYN
Middle Name:TAMANO
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:GLORILYN
Other - Middle Name:HORNILLA
Other - Last Name:TAMANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:164 W. HOSPITALITY LANE, STE.7
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3329
Mailing Address - Country:US
Mailing Address - Phone:909-383-5000
Mailing Address - Fax:909-383-5010
Practice Address - Street 1:164 W. HOSPITALITY LANE, STE.7
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3329
Practice Address - Country:US
Practice Address - Phone:909-383-5000
Practice Address - Fax:909-383-5010
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BV346YOtherMEDICARE PTAN
BV346YMedicare PIN