Provider Demographics
NPI:1336104389
Name:MCDONALD, GLENN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:MCDONALD
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 1:3535 N FOURTH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0037
Mailing Address - Country:US
Mailing Address - Phone:903-234-9992
Mailing Address - Fax:903-234-8287
Practice Address - Street 1:3535 N FOURTH ST STE 301
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-0037
Practice Address - Country:US
Practice Address - Phone:903-234-9992
Practice Address - Fax:903-234-8287
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA308302207RN0300X
TXJ0114207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752896100OtherCOMMERCIAL
TX8B0772OtherBLUE CROSS & BLUE SHIELD
TX8B0772OtherBLUE CROSS & BLUE SHIELD
TXF58833Medicare UPIN
TX752896100OtherCOMMERCIAL