Provider Demographics
NPI:1689825119
Name:PODGAETZ GLIKSBERG, EITAN (MD)
Entity Type:Individual
Prefix:
First Name:EITAN
Middle Name:
Last Name:PODGAETZ GLIKSBERG
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 1:3410 WORTH ST STE 235
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2071
Mailing Address - Country:US
Mailing Address - Phone:469-800-7370
Mailing Address - Fax:
Practice Address - Street 1:3410 WORTH ST, SUITE 235
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:469-800-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51235208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR0300OtherTX LICENSE #
MN020002632Medicare PIN