Provider Demographics
NPI:1689606311
Name:WEISSMAN, GLENN HARMON (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:HARMON
Last Name:WEISSMAN
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 1:51 N FIFTH AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-3739
Mailing Address - Country:US
Mailing Address - Phone:626-357-6222
Mailing Address - Fax:626-357-0115
Practice Address - Street 1:51 N. FIFTH AVE., STE. 202
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3739
Practice Address - Country:US
Practice Address - Phone:626-357-6222
Practice Address - Fax:626-357-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41381174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G413810Medicaid
CA00G413810Medicaid
CAA48555Medicare UPIN