Provider Demographics
NPI:1003806431
Name:DAVIS, GLENN R (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2255 E MOSSY OAKS RD STE 680
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-1812
Mailing Address - Country:US
Mailing Address - Phone:281-537-0300
Mailing Address - Fax:281-537-0315
Practice Address - Street 1:2255 E MOSSY OAKS RD STE 680
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-1812
Practice Address - Country:US
Practice Address - Phone:281-537-0300
Practice Address - Fax:281-537-0315
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK38899207R00000X
TXK5503208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110240334OtherMEDICARE RAILROAD PIN
TX110240334OtherMEDICARE RAILROAD PIN
TXH36595Medicare UPIN