Provider Demographics
NPI:1881704252
Name:STOCKBRIDGE, GLENN ROLAND (DPM)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ROLAND
Last Name:STOCKBRIDGE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 TANGLEWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7165
Mailing Address - Country:US
Mailing Address - Phone:432-367-9944
Mailing Address - Fax:432-368-7600
Practice Address - Street 1:3912 TANGLEWOOD LANE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7165
Practice Address - Country:US
Practice Address - Phone:432-367-9944
Practice Address - Fax:432-368-7600
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX1201213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H26RMedicare PIN
U28141Medicare UPIN