Provider Demographics
NPI:1245326883
Name:GLASSMAN, JERROLD (MD)
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:GLASSMAN
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 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 650
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-819-7222
Mailing Address - Fax:619-299-5023
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 650
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-819-7222
Practice Address - Fax:619-299-5023
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34309207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953712511OtherTRICARE
CA00G343090OtherBLUE SHIELD
CA00G343090Medicaid
CA953712511OtherTRICARE
CA00G343090Medicaid