Provider Demographics
NPI:1902033210
Name:GLENN, ROBERT CLIFTON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CLIFTON
Last Name:GLENN
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 1:2319 SAINT MATTHEWS RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2042
Mailing Address - Country:US
Mailing Address - Phone:803-536-1571
Mailing Address - Fax:
Practice Address - Street 1:308 W STATE ST STE 3D
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4653
Practice Address - Country:US
Practice Address - Phone:909-566-9669
Practice Address - Fax:909-353-4985
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3324292084P0800X
SC317372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC317375Medicaid
LA332429OtherMEDICAL LICENSE