Provider Demographics
NPI:1790911139
Name:MONK, GLEN OWEN
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:OWEN
Last Name:MONK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SUGAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-9264
Mailing Address - Country:US
Mailing Address - Phone:501-749-7445
Mailing Address - Fax:
Practice Address - Street 1:2400 SUGAR HILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-9264
Practice Address - Country:US
Practice Address - Phone:501-749-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7037208D00000X, 207P00000X, 207Q00000X
TXQ2467207P00000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine