Provider Demographics
NPI:1720069834
Name:PU, GLEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:PU
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 1:950 COUNTY ROAD 553
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-0345
Mailing Address - Country:US
Mailing Address - Phone:803-381-7497
Mailing Address - Fax:
Practice Address - Street 1:950 COUNTY ROAD 553
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-0345
Practice Address - Country:US
Practice Address - Phone:803-381-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0429212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52614708 012OtherBCBS
GA000728351QMedicaid
TX8BJ664OtherBCBS
GAF54449Medicare UPIN
TX8L3971Medicare PIN
GA30BDNLTMedicare PIN