Provider Demographics
NPI:1720023070
Name:PICKENS, GLYNN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLYNN
Middle Name:JOHN
Last Name:PICKENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:PICKENS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 1205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:890 ROCKWALL PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6872
Practice Address - Country:US
Practice Address - Phone:972-276-6191
Practice Address - Fax:972-454-6893
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0199208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045376302Medicaid
TX045376302Medicaid
TX8G2556Medicare PIN