Provider Demographics
NPI:1407854920
Name:BEEDE, GLEN ALAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ALAN
Last Name:BEEDE
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 1:5521 BELLAIRE DR S
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-5855
Mailing Address - Country:US
Mailing Address - Phone:817-763-9383
Mailing Address - Fax:817-763-9385
Practice Address - Street 1:5521 BELLAIRE DR S
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-5855
Practice Address - Country:US
Practice Address - Phone:817-763-9383
Practice Address - Fax:817-763-9385
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1317213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80790BMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
TX0012AKMedicare ID - Type UnspecifiedGROUP MEDICARE #
TXU56678Medicare UPIN