Provider Demographics
NPI:1740311034
Name:SHIRK, GLEN W (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:W
Last Name:SHIRK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1524 MCHENRY AVE
Mailing Address - Street 2:SUITE 370
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4568
Mailing Address - Country:US
Mailing Address - Phone:209-527-7741
Mailing Address - Fax:209-527-7608
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 370
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-527-7741
Practice Address - Fax:209-527-7608
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA23879208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics