Odyssey Medical Group

Primary specialty

SpecialistTaxonomy code 174400000X

License

G79180 Issued in CA

Legal business name

ODYSSEY MEDICAL GROUP

Practice address

4832 Lincoln Blvd
Marina del Rey, CA 90292-6917

Phone

(310) 821-7658

Fax

(310) 821-1708

NPI assigned

May 2, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Marica Glenn, M.D

Title

Owner

Phone

(310) 821-7658

Specialties & licenses 4

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178064000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1932320256",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4832 LINCOLN BLVD",
            "city": "MARINA DEL REY",
            "state": "CA",
            "postal_code": "902926917",
            "telephone_number": "310-821-7658",
            "fax_number": "310-821-1708"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4832 LINCOLN BLVD",
            "city": "MARINA DEL REY",
            "state": "CA",
            "postal_code": "902926917",
            "telephone_number": "310-821-7658",
            "fax_number": "310-821-1708"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ODYSSEY MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-02",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GLENN",
        "authorized_official_first_name": "MARICA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "310-821-7658",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "CA",
            "license": "E4238",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "CA",
            "license": "G79180",
            "primary": true
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "CA",
            "license": "C35069",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "CA",
            "license": "A96388",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Specialist in Marina del Rey, CA
• Providers in Marina del Rey, CA by specialty
• Specialist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.