Provider Demographics
NPI:1902822059
Name:MATNEY, GLENN PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:PAUL
Last Name:MATNEY
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 1:12402 INDUSTRIAL BLVD STE B1
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5889
Mailing Address - Country:US
Mailing Address - Phone:760-245-9363
Mailing Address - Fax:
Practice Address - Street 1:12402 INDUSTRIAL BLVD STE B1
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5889
Practice Address - Country:US
Practice Address - Phone:760-245-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG069064207QA0401X, 2083A0300X, 2084A0401X, 208000000X
CAG690642084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G690641 8757126Medicaid
F21967Medicare UPIN