Provider Demographics
NPI:1528005378
Name:DAUBERT, GLENN P (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:P
Last Name:DAUBERT
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 1:11605 BOOM POINTER WAY
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7625
Mailing Address - Country:US
Mailing Address - Phone:916-708-3972
Mailing Address - Fax:
Practice Address - Street 1:6900 BRUCEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823
Practice Address - Country:US
Practice Address - Phone:916-688-2535
Practice Address - Fax:916-688-2350
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52359207P00000X, 207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104625314Medicaid
MIGD078739OtherBS/BS OF MICHIGAN
MII17717Medicare UPIN
MIGD078739OtherBS/BS OF MICHIGAN