Provider Demographics
NPI:1689648040
Name:GRAVES, GLEN S (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:S
Last Name:GRAVES
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 1:5777 NEW COPELAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3905
Mailing Address - Country:US
Mailing Address - Phone:903-561-9255
Mailing Address - Fax:
Practice Address - Street 1:5777 NEW COPELAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-561-9255
Practice Address - Fax:903-561-0034
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2036207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104034703Medicaid
TX8F3429Medicare PIN
TX104034703Medicaid