Provider Demographics
NPI:1730172461
Name:SOPPE, GLENN G (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:G
Last Name:SOPPE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:345 SAXONY RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2787
Mailing Address - Country:US
Mailing Address - Phone:760-944-8402
Mailing Address - Fax:
Practice Address - Street 1:345 SAXONY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2787
Practice Address - Country:US
Practice Address - Phone:760-944-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE38417Medicare UPIN
CAWG64239GMedicare PIN