Provider Demographics
NPI:1366494023
Name:GLASS, RENEE F (MD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:F
Last Name:GLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34307
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-4307
Mailing Address - Country:US
Mailing Address - Phone:866-752-2080
Mailing Address - Fax:866-752-2240
Practice Address - Street 1:501 WASHINGTON ST
Practice Address - Street 2:STE 510
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-819-6577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG482322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G482320Medicaid
CAWG48232BMedicare PIN
CAWG48232HMedicare PIN
CA00G482322Medicare PIN
E85026Medicare UPIN
CAWG48232FMedicare PIN
CA300036955Medicare PIN
CAWG48232GMedicare PIN
CAWG48232AMedicare PIN
CA00G482320Medicaid