Provider Demographics
NPI:1780687319
Name:PUGACH, ROBERT GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GLENN
Last Name:PUGACH
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 1:3801 KATELLA AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3371
Mailing Address - Country:US
Mailing Address - Phone:562-594-0860
Mailing Address - Fax:562-594-9010
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:STE 110
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3371
Practice Address - Country:US
Practice Address - Phone:562-594-0860
Practice Address - Fax:562-594-9010
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41822174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A418220Medicaid
CA00A418220Medicaid
CAWA41822AMedicare ID - Type Unspecified