Provider Demographics
NPI:1326059577
Name:GUILLET, GLEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:G
Last Name:GUILLET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 N MAJOR DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77713-9013
Mailing Address - Country:US
Mailing Address - Phone:409-896-5901
Mailing Address - Fax:409-896-5910
Practice Address - Street 1:5875 N MAJOR DR
Practice Address - Street 2:SUITE 214
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77713-9013
Practice Address - Country:US
Practice Address - Phone:409-896-5901
Practice Address - Fax:409-896-5910
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X9020OtherBCBS
TX8F6213Medicare PIN
TXB23177Medicare UPIN