Provider Demographics
NPI:1659373983
Name:TISMAN, GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:TISMAN
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 1:13025 BAILEY ST
Mailing Address - Street 2:STE A
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90601-4212
Mailing Address - Country:US
Mailing Address - Phone:562-789-8822
Mailing Address - Fax:562-698-4582
Practice Address - Street 1:13025 BAILEY ST
Practice Address - Street 2:STE A
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90601-4212
Practice Address - Country:US
Practice Address - Phone:562-789-8822
Practice Address - Fax:562-698-4582
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-03-05
Deactivation Date:2006-06-01
Deactivation Code:
Reactivation Date:2006-06-28
Provider Licenses
StateLicense IDTaxonomies
CAG19173A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG19173BMedicare PIN
CAA40555Medicare UPIN