Provider Demographics
NPI:1750429643
Name:TOLBERT, GLENNA PATRISE (MD)
Entity type:Individual
Prefix:DR
First Name:GLENNA
Middle Name:PATRISE
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17609 VENTURA BLVD
Mailing Address - Street 2:STE 114
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-784-7197
Mailing Address - Fax:818-784-3060
Practice Address - Street 1:17609 VENTURA BLVD
Practice Address - Street 2:STE 114
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:818-784-7197
Practice Address - Fax:818-784-3060
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70820208100000X, 2081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G708200Medicaid
CA00G708200Medicaid
G70820AMedicare PIN