Provider Demographics
NPI:1346247749
Name:WOOD, GLENN GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:GORDON
Last Name:WOOD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9411 N LAMAR BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-4179
Mailing Address - Country:US
Mailing Address - Phone:512-583-9679
Mailing Address - Fax:512-233-0985
Practice Address - Street 1:7112 ED BLUESTEIN BLVD
Practice Address - Street 2:STE 100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2900
Practice Address - Country:US
Practice Address - Phone:512-744-6000
Practice Address - Fax:512-583-5462
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXF4706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE14307Medicare UPIN
TX130823105Medicaid
TXE14307Medicare UPIN
TX153715101Medicaid
TX082009401Medicaid