Provider Demographics
NPI:1265456602
Name:MILLER, GLENN R (DPM)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:MILLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 S STAPLES ST STE 103
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5543
Mailing Address - Country:US
Mailing Address - Phone:361-814-4055
Mailing Address - Fax:361-814-1346
Practice Address - Street 1:7101 S STAPLES ST STE 103
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5543
Practice Address - Country:US
Practice Address - Phone:361-814-4055
Practice Address - Fax:361-814-1346
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1441213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030428901Medicaid
TX00487EMedicare PIN
TX5335060001Medicare NSC