Provider Demographics
NPI:1982782439
Name:HART, GLEN WOODFORD II (OD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:WOODFORD
Last Name:HART
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:226 RICHMOND RANCH RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1083
Mailing Address - Country:US
Mailing Address - Phone:903-831-5974
Mailing Address - Fax:903-838-9558
Practice Address - Street 1:226 RICHMOND RANCH RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1083
Practice Address - Country:US
Practice Address - Phone:903-831-5974
Practice Address - Fax:903-838-9558
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4479T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00944EMedicare ID - Type UnspecifiedPIN#U19405