Provider Demographics
NPI:1457779266
Name:GLENN, JOHN MOLLOY III (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MOLLOY
Last Name:GLENN
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2250 HAYES ST STE 302
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1078
Practice Address - Country:US
Practice Address - Phone:415-379-2900
Practice Address - Fax:415-666-3144
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2023-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19585208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457779266Medicaid