Provider Demographics
NPI:1629012612
Name:GLASS, EDWIN CHAPMAN (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:CHAPMAN
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWIN
Other - Middle Name:
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3271 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1735
Mailing Address - Country:US
Mailing Address - Phone:310-390-0761
Mailing Address - Fax:310-268-4916
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 810
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4803
Practice Address - Country:US
Practice Address - Phone:310-829-9788
Practice Address - Fax:310-268-4916
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC35240207U00000X, 207UN0901X, 207UN0902X, 207UN0903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No207UN0903XAllopathic & Osteopathic PhysiciansNuclear MedicineIn Vivo & In Vitro Nuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C352400Medicaid
CA00C352400OtherBLUE SHIELD
CA00C352400OtherBLUE SHIELD
CAWC35240BMedicare ID - Type Unspecified