Provider Demographics
NPI:1922421171
Name:RONALD GLOUSMAN MD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RONALD GLOUSMAN MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:GLOUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-9116
Mailing Address - Street 1:PO BOX 570627
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-0627
Mailing Address - Country:US
Mailing Address - Phone:310-659-9116
Mailing Address - Fax:866-807-7466
Practice Address - Street 1:999 N TUSTIN AVE
Practice Address - Street 2:STE 114
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3528
Practice Address - Country:US
Practice Address - Phone:714-508-1981
Practice Address - Fax:866-807-7466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104897289OtherINDIVIDUAL NPI
CA1104897289OtherINDIVIDUAL NPI
CAEW675ZMedicare PIN