Provider Demographics
NPI:1710964333
Name:JABOLA, GLENN M (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:JABOLA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:74020 ALESSANDRO DR STE B
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-3707
Mailing Address - Country:US
Mailing Address - Phone:760-837-8827
Mailing Address - Fax:760-773-1225
Practice Address - Street 1:74020 ALESSANDRO DR STE B
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-837-8827
Practice Address - Fax:760-773-1225
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2018-06-13
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Provider Licenses
StateLicense IDTaxonomies
CAA52068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A520680Medicare ID - Type UnspecifiedNHIC MEDICARE
CAF79438Medicare UPIN