Provider Demographics
NPI:1407900590
Name:ELLISOR, GLENN D (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:ELLISOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 GOLDEN POND DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77345-1636
Mailing Address - Country:US
Mailing Address - Phone:281-359-2020
Mailing Address - Fax:281-359-7019
Practice Address - Street 1:1714 KINGWOOD DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3046
Practice Address - Country:US
Practice Address - Phone:281-359-2020
Practice Address - Fax:281-359-7019
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03337TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81071QOtherBLUE CROSS
TX8372B9Medicare ID - Type Unspecified
TX81071QOtherBLUE CROSS