Provider Demographics
NPI:1942220330
Name:GLAVINOVICH, JOHN LUKE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LUKE
Last Name:GLAVINOVICH
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 1:456 PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1278
Mailing Address - Country:US
Mailing Address - Phone:949-307-6210
Mailing Address - Fax:949-497-4225
Practice Address - Street 1:4330 BARRANCA PARKWAY
Practice Address - Street 2:SUITE 112
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4755
Practice Address - Country:US
Practice Address - Phone:949-307-6210
Practice Address - Fax:949-497-4225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31910207P00000X, 2083P0011X, 208D00000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G319100OtherBLUE SHIELD
CA00G319100Medicaid
CA930107459OtherRAILROAD MEDICARE
CAA44909Medicare UPIN
CAWG31910CMedicare ID - Type Unspecified
CAWG31910HMedicare ID - Type Unspecified
CA00G319100Medicaid