Provider Demographics
NPI:1821179698
Name:HANSEN, GLENN EUGENE (DO,)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EUGENE
Last Name:HANSEN
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 1:2520 HARWOOD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-6709
Mailing Address - Country:US
Mailing Address - Phone:817-267-6222
Mailing Address - Fax:
Practice Address - Street 1:2520 HARWOOD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6709
Practice Address - Country:US
Practice Address - Phone:817-267-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9976208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine