Provider Demographics
NPI:1033135876
Name:PETERS-DO, GLENDA JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:JEAN
Last Name:PETERS-DO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9900 S IH 35
Mailing Address - Street 2:TEXAS MEDCLINIC
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-3885
Mailing Address - Country:US
Mailing Address - Phone:512-291-5577
Mailing Address - Fax:512-291-5576
Practice Address - Street 1:9900 S IH 35
Practice Address - Street 2:TEXAS MEDCLINIC
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-3885
Practice Address - Country:US
Practice Address - Phone:512-291-5577
Practice Address - Fax:512-291-5576
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ8713OtherTEXAS MEDICAL LICENSE
TX1119812-01Medicaid
TX72-1564406OtherFEDERAL TAX ID
TXG20728Medicare UPIN
TX72-1564406OtherFEDERAL TAX ID
TX00570VMedicare ID - Type UnspecifiedGROUP NUMBER