Individual
DR. GLENN PROVOST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
17100 EUCLID ST, FOUNTAIN VALLEY, CA 92708-4004
(714) 979-1211
Mailing address
9111 MAHALO DR, HUNTINGTON BEACH, CA 92646-7863
(714) 401-9117
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
G79498
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G794980
—
CA
Enumeration date
04/20/2006
Last updated
04/11/2016
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