Provider Demographics
NPI:1013962661
Name:GLIDDEN, GEOFFREY GLYNN (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:GLYNN
Last Name:GLIDDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GEOFFREY
Other - Middle Name:G
Other - Last Name:GLIDDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:4090 MAPLESHADE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-0025
Mailing Address - Country:US
Mailing Address - Phone:972-608-9777
Mailing Address - Fax:972-403-1555
Practice Address - Street 1:4090 MAPLESHADE LN
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-0024
Practice Address - Country:US
Practice Address - Phone:972-608-9777
Practice Address - Fax:972-403-1555
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3141207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
B23009Medicare UPIN
TX0084ADMedicare PIN