Provider Demographics
NPI:1629054986
Name:HOLLEY, GLEN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:EDWARD
Last Name:HOLLEY
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1657207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131684609Medicaid
TX83751KOtherBCBS
TX131684602Medicaid
TX131684610Medicaid
TX131684611Medicaid
TX050065906OtherRAILROAD
TX131684603Medicaid
TX131684607Medicaid
TX131684608Medicaid
TX131684612Medicaid
TX8EH086OtherBCBS TX
TX131684607Medicaid
TX131684609Medicaid
TX050065906OtherRAILROAD
C17033Medicare UPIN
TX131684602Medicaid
TX131684603Medicaid
TXTXB114057Medicare PIN