Provider Demographics
NPI:1558364588
Name:GARNER, GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:GARNER
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 1:11920 ASTORIA BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6097
Mailing Address - Country:US
Mailing Address - Phone:281-929-4420
Mailing Address - Fax:281-929-4421
Practice Address - Street 1:11914 ASTORIA BLVD STE 575
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6080
Practice Address - Country:US
Practice Address - Phone:281-929-4420
Practice Address - Fax:281-929-4421
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4689174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152279901Medicaid
TX152279901Medicaid
TXH65352Medicare UPIN