Provider Demographics
NPI:1881662211
Name:GLOVER, SORRELL N (MD)
Entity Type:Individual
Prefix:
First Name:SORRELL
Middle Name:N
Last Name:GLOVER
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 1:2190 LYNN RD
Mailing Address - Street 2:STE 220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:805-495-8050
Mailing Address - Fax:805-496-2160
Practice Address - Street 1:215 W JANSS RD
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-373-8582
Practice Address - Fax:805-373-6865
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4456207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G44560Medicaid
WG4456DMedicare ID - Type Unspecified
A56500Medicare UPIN