Provider Demographics
NPI:1821225012
Name:GLEGHORN, JANIE KEESLING VESTAL (MD)
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:KEESLING VESTAL
Last Name:GLEGHORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANIE
Other - Middle Name:KEESLING
Other - Last Name:VESTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:330 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2432
Mailing Address - Country:US
Mailing Address - Phone:417-848-3640
Mailing Address - Fax:
Practice Address - Street 1:1156 HIGH ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95064-1077
Practice Address - Country:US
Practice Address - Phone:831-459-2211
Practice Address - Fax:831-459-3546
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2H74207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1821225012Medicaid
MOP00894278OtherRR MEDICARE
MOMA1327060Medicare PIN
MOP00894278OtherRR MEDICARE