Provider Demographics
NPI:1972504652
Name:O'SULLIVAN, GLEN S (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:S
Last Name:O'SULLIVAN
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 1:635 LASSEN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9003
Mailing Address - Country:US
Mailing Address - Phone:866-668-3597
Mailing Address - Fax:866-301-6641
Practice Address - Street 1:635 LASSEN LN
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9003
Practice Address - Country:US
Practice Address - Phone:866-668-3597
Practice Address - Fax:866-301-6641
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29768Medicare UPIN
CA00A442190Medicare ID - Type Unspecified