Provider Demographics
NPI:1588614564
Name:SLOCUM, GLENN R (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:SLOCUM
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 1:74 HARVEY CT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92617-4070
Mailing Address - Country:US
Mailing Address - Phone:949-725-6437
Mailing Address - Fax:
Practice Address - Street 1:74 HARVEY CT
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92617-4070
Practice Address - Country:US
Practice Address - Phone:949-725-6437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG745782085R0202X
AZ451372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00449079OtherRAILROAD MEDICARE
CA00G745780Medicaid
CA00G745780OtherBLUE SHIELD
CAAR207WMedicare PIN
WG74578CMedicare PIN
P00449079OtherRAILROAD MEDICARE
G42068Medicare UPIN
CA00G745780Medicaid