Provider Demographics
NPI:1629073648
Name:HACK, GLENDON SALDIVAR (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENDON
Middle Name:SALDIVAR
Last Name:HACK
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 324
Mailing Address - Street 2:
Mailing Address - City:VON ORMY
Mailing Address - State:TX
Mailing Address - Zip Code:78073-0324
Mailing Address - Country:US
Mailing Address - Phone:830-709-9960
Mailing Address - Fax:830-709-9962
Practice Address - Street 1:19432 DAVIS ST
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052
Practice Address - Country:US
Practice Address - Phone:830-709-9960
Practice Address - Fax:830-709-9962
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7753207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U6150OtherBCBS INDIVIDUAL
TX135816011Medicaid
TX135816011Medicaid
TX8U6150OtherBCBS INDIVIDUAL