Provider Demographics
NPI:1881665586
Name:WALDMAN, GLENN ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ERIC
Last Name:WALDMAN
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 1:415 ROLLING OAKS DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1029
Mailing Address - Country:US
Mailing Address - Phone:805-494-4797
Mailing Address - Fax:805-494-4810
Practice Address - Street 1:415 ROLLING OAKS DR
Practice Address - Street 2:SUITE 190
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1029
Practice Address - Country:US
Practice Address - Phone:805-494-4797
Practice Address - Fax:805-494-4810
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62183174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A62183AMedicaid
CAA62183AMedicare ID - Type Unspecified
CA00A62183AMedicaid