Provider Demographics
NPI:1649315508
Name:GLENN, CASPER (MD)
Entity type:Individual
Prefix:DR
First Name:CASPER
Middle Name:
Last Name:GLENN
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 1:5450 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2002
Mailing Address - Country:US
Mailing Address - Phone:310-305-9200
Mailing Address - Fax:
Practice Address - Street 1:5450 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2002
Practice Address - Country:US
Practice Address - Phone:310-305-9200
Practice Address - Fax:310-305-2800
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50893146D00000X
CAG48007146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW932Medicare ID - Type Unspecified
CAW809AMedicare ID - Type Unspecified
CAWG48007SMedicare UPIN
CAW809FMedicare ID - Type Unspecified
CAW809BMedicare ID - Type Unspecified
CAW809CMedicare ID - Type Unspecified