Provider Demographics
NPI:1205944196
Name:HARRIS, GLENNA G (MD, FAAP)
Entity type:Individual
Prefix:DR
First Name:GLENNA
Middle Name:G
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 LONDONDERRY LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-5337
Mailing Address - Country:US
Mailing Address - Phone:940-484-0065
Mailing Address - Fax:940-484-2205
Practice Address - Street 1:515 LONDONDERRY LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-5337
Practice Address - Country:US
Practice Address - Phone:940-484-0065
Practice Address - Fax:940-484-2205
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1626208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134906002Medicaid
TX0097BDOtherBC/BS
TX0028590OtherAMERIGROUP
TX134906002Medicaid
F79925Medicare UPIN