Provider Demographics
NPI:1689686610
Name:MEDELLIN, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:MEDELLIN
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 87
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78291-0087
Mailing Address - Country:US
Mailing Address - Phone:210-358-9172
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:903 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:210-358-9658
Practice Address - Fax:210-358-3450
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3796208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125095308Medicaid
TX125095307Medicaid
TX125095307OtherCSHCN
TX125095309OtherMEDICAID CSHCN
TX8C1006Medicare PIN
TX125095307Medicaid