Provider Demographics
NPI:1013021161
Name:GLASS, MARK WILLIAM
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:GLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5927 E UNIVERSITY BLVD APT 221
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-9114
Mailing Address - Country:US
Mailing Address - Phone:214-926-7117
Mailing Address - Fax:
Practice Address - Street 1:17051 DALLAS PKWY STE 400
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7108
Practice Address - Country:US
Practice Address - Phone:214-370-3535
Practice Address - Fax:214-370-0004
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02857363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209276607Medicaid
TX806N48OtherBLUE CROSS/BLUE PIN
TX806N48OtherBLUE CROSS/BLUE PIN