Provider Demographics
NPI:1952307894
Name:HANANOUCHI, GLENN ISAMU (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ISAMU
Last Name:HANANOUCHI
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 1:231 W FIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-0220
Mailing Address - Country:US
Mailing Address - Phone:559-297-0300
Mailing Address - Fax:559-323-5461
Practice Address - Street 1:231 W FIR AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-0220
Practice Address - Country:US
Practice Address - Phone:559-297-0300
Practice Address - Fax:559-323-5461
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5789302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G578930Medicaid
CA00G578932Medicare PIN
CA00G578930Medicare ID - Type Unspecified
CA00G578934Medicare PIN
CAF38088Medicare UPIN