Provider Demographics
NPI:1700378635
Name:GLENN, ANDREW MARK (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARK
Last Name:GLENN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 NOLAN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NOLANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76559-4639
Mailing Address - Country:US
Mailing Address - Phone:775-219-5861
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-288-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2091208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice