Provider Demographics
NPI:1962494914
Name:MINOR, GLADYS IRENE (MD)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:IRENE
Last Name:MINOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 RIVER WALK TRL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-5377
Mailing Address - Country:US
Mailing Address - Phone:512-943-0914
Mailing Address - Fax:
Practice Address - Street 1:835 RIVER WALK TRL
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-5377
Practice Address - Country:US
Practice Address - Phone:512-943-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010559722085R0001X
TXR44332085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01155989OtherRAILROAD MEDICARE PIN
IN200374430Medicaid
INP00103259OtherRAILROAD MEDICARE PIN
IN200374430Medicaid
INM400056787Medicare PIN
351348013OtherTAX ID NUMBER
IN200374430Medicaid