Provider Demographics
NPI:1487676656
Name:THIEL, GLENN W (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:W
Last Name:THIEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 12TH ST STE 250
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-1929
Mailing Address - Country:US
Mailing Address - Phone:916-550-5487
Mailing Address - Fax:530-273-7255
Practice Address - Street 1:1710 PRAIRIE CITY RD STE 125
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4042
Practice Address - Country:US
Practice Address - Phone:916-737-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG70524Medicare UPIN