Provider Demographics
NPI:1013123892
Name:KISSINGER, GLENN C (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:C
Last Name:KISSINGER
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 1:271 NORTH L STREET
Mailing Address - Street 2:
Mailing Address - City:DINUBA
Mailing Address - State:CA
Mailing Address - Zip Code:93618-2107
Mailing Address - Country:US
Mailing Address - Phone:559-591-1820
Mailing Address - Fax:559-591-8225
Practice Address - Street 1:271 NORTH L STREET
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618-2107
Practice Address - Country:US
Practice Address - Phone:559-591-1820
Practice Address - Fax:559-591-8225
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21726207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A82487Medicare UPIN
CA00A217261Medicare ID - Type Unspecified