Provider Demographics
NPI:1982923975
Name:GLASS, SHANNON B (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:GLASS
Suffix:
Gender:F
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:11937 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708
Practice Address - Country:US
Practice Address - Phone:903-877-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ16112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP02057868OtherMEDICARE RAIL ROAD
TX8JW906OtherBCBS
TXP02057870OtherMEDICARE RAIL ROAD
TX348611003Medicaid
TX348611004Medicaid
TX667447OtherMEDICARE
TX667934OtherMEDICARE
TX8JP975OtherBCBS