Provider Demographics
NPI:1639255060
Name:MADOKORO, GLENN DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:DOUGLAS
Last Name:MADOKORO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2323 CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-5124
Mailing Address - Country:US
Mailing Address - Phone:949-548-8800
Mailing Address - Fax:855-324-3537
Practice Address - Street 1:2901 W COAST HWY STE 200
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4045
Practice Address - Country:US
Practice Address - Phone:949-548-8800
Practice Address - Fax:949-548-0248
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2022-12-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG30192207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB51070Medicare UPIN
CAW017AMedicare ID - Type Unspecified