Provider Demographics
NPI:1205887973
Name:WILLIE, GLEN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ROBERT
Last Name:WILLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-2230
Mailing Address - Country:US
Mailing Address - Phone:903-465-2440
Mailing Address - Fax:903-465-2298
Practice Address - Street 1:900 N ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-2230
Practice Address - Country:US
Practice Address - Phone:903-465-2440
Practice Address - Fax:903-465-2298
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0858174400000X, 207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86170YOtherBLUE CROSS BLUE SHIELD
TX122390105Medicaid
TX8155B0Medicare ID - Type Unspecified
TXC23585Medicare UPIN
TX122390105Medicaid