Provider Demographics
NPI:1134201866
Name:FOOTHILL FAMILY PRACTICE MEDICAL GROUP INC
Entity type:Organization
Organization Name:FOOTHILL FAMILY PRACTICE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GLAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-963-9402
Mailing Address - Street 1:440 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3361
Mailing Address - Country:US
Mailing Address - Phone:626-963-9402
Mailing Address - Fax:626-623-7244
Practice Address - Street 1:440 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3361
Practice Address - Country:US
Practice Address - Phone:626-963-9402
Practice Address - Fax:626-623-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1141Medicare ID - Type Unspecified