Individual
GLEN S O'SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
635 LASSEN LN, MOUNT SHASTA, CA 96067-9003
(866) 668-3597
(866) 301-6641
Mailing address
635 LASSEN LN, MOUNT SHASTA, CA 96067-9003
(866) 668-3597
(866) 301-6641
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
A44219
CA
Other
Enumeration date
08/03/2005
Last updated
11/23/2010
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