Provider Demographics
NPI:1306867924
Name:GLASS, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4601 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:BUILDING 4 SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4601 SPICEWOOD SPRINGS RD
Practice Address - Street 2:BUILDING 4, SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8598
Practice Address - Country:US
Practice Address - Phone:512-467-1376
Practice Address - Fax:512-467-8658
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXF59192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035680001Medicaid
TX00RA73Medicare ID - Type Unspecified
TX035680001Medicaid