Provider Demographics
NPI:1780731976
Name:GLENN, MARCIA JANEL (MD)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:JANEL
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:447 N PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1413
Mailing Address - Country:US
Mailing Address - Phone:310-821-7658
Mailing Address - Fax:424-309-9057
Practice Address - Street 1:447 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1413
Practice Address - Country:US
Practice Address - Phone:310-821-7658
Practice Address - Fax:424-309-9057
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG63373207NP0225X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG63373Medicare ID - Type Unspecified