Provider Demographics
NPI:1467676668
Name:UNDERWOOD, GLEN ALLAN (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:ALLAN
Last Name:UNDERWOOD
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 1:2700 US HIGHWAY 281
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-3810
Mailing Address - Country:US
Mailing Address - Phone:830-798-8585
Mailing Address - Fax:830-693-1052
Practice Address - Street 1:2700 US HIGHWAY 281
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-3810
Practice Address - Country:US
Practice Address - Phone:830-798-8585
Practice Address - Fax:830-693-1052
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5322T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU 74814Medicare UPIN
TX8C9324Medicare ID - Type Unspecified