Provider Demographics
NPI:1700057163
Name:GLENN R MILLER DPM
Entity Type:Organization
Organization Name:GLENN R MILLER DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:361-814-4055
Mailing Address - Street 1:7101 S STAPLES ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5542
Mailing Address - Country:US
Mailing Address - Phone:361-814-4055
Mailing Address - Fax:361-814-1346
Practice Address - Street 1:7101 S STAPLES ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5542
Practice Address - Country:US
Practice Address - Phone:361-814-4055
Practice Address - Fax:361-814-1346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1441213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030428901Medicaid
TX030428901Medicaid
TX00487EMedicare PIN