Provider Demographics
NPI:1922460401
Name:HUANG, GLEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:HUANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RUOGU
Other - Middle Name:
Other - Last Name:HUANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:WAKE FOREST SCHOOL OF MEDICINE MEDICAL BLVD
Mailing Address - Street 2:WATLINGTON HALL, 3RD FLOOR
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-4305
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE RM 37121CHS
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-8373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine