Provider Demographics
NPI:1902108764
Name:MILLER, GLENN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:EDWARD
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1431 OCEAN AVENUE
Mailing Address - Street 2:#720
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2148
Mailing Address - Country:US
Mailing Address - Phone:310-963-6433
Mailing Address - Fax:310-260-7976
Practice Address - Street 1:1431 OCEAN AVENUE
Practice Address - Street 2:#720
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2148
Practice Address - Country:US
Practice Address - Phone:310-963-6433
Practice Address - Fax:310-260-7976
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2012-08-07
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Provider Licenses
StateLicense IDTaxonomies
CAG 29077207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG20977OtherG20977