Provider Demographics
NPI:1770826976
Name:GLENN, MELODY JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MELODY
Middle Name:JEAN
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 LONE TREE WAY
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6200
Mailing Address - Country:US
Mailing Address - Phone:323-332-7821
Mailing Address - Fax:
Practice Address - Street 1:3901 LONE TREE WAY
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6200
Practice Address - Country:US
Practice Address - Phone:323-332-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0782207P00000X
390200000X
NM390200000X
CAA141103207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program