Provider Demographics
NPI:1720141286
Name:WILCOX, GLENN LOCKHART (DOM)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:LOCKHART
Last Name:WILCOX
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 WYOMING BLVD NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3132
Mailing Address - Country:US
Mailing Address - Phone:505-771-4998
Mailing Address - Fax:
Practice Address - Street 1:5353 WYOMING BLVD NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3132
Practice Address - Country:US
Practice Address - Phone:505-771-4998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM34RX2208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice