Basic Information
| Provider Information | |||||||||
| NPI: | 1003806431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 E MOSSY OAKS RD STE 680 | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773891812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815370300 | ||||||||
| FaxNumber: | 2815370315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 E MOSSY OAKS RD STE 680 | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773891812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815370300 | ||||||||
| FaxNumber: | 2815370315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 38899 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | K5503 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | K5503 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110240334 | 01 | TX | MEDICARE RAILROAD PIN | OTHER |