Provider Demographics
NPI:1912967894
Name:MIYA, GLENN YUKIO (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:YUKIO
Last Name:MIYA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:CHAPARRAL MEDICAL GROUP
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:430 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1607
Practice Address - Country:US
Practice Address - Phone:909-621-3916
Practice Address - Fax:909-625-0903
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-12-03
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Provider Licenses
StateLicense IDTaxonomies
CAG70876208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G708760Medicaid
CAG70876Medicare ID - Type Unspecified
CA00G708760Medicaid